Job Overview
Location
USA, TN, Chattanooga, Remote
Job Type
Full-time
Category
Human Resources
Date Posted
May 7, 2026
Full Job Description
📋 Description
- • The Clinical Review Manager supports Commercial lines of business by conducting comprehensive clinical reviews of medical service requests using established criteria, ensuring appropriate care and compliance with clinical standards and policies.
- • Day-to-day responsibilities include reviewing cases in turnaround-time order, meeting deadlines, prioritizing urgent or escalated cases, initiating referrals for care coordination, consulting with the Medical Director on complex cases, and performing appeals, denial interpretations, retrospective reviews, and pre-certifications using medical appropriateness criteria and clinical judgment.
- • The role is part of the Commercial team at BlueCross BlueShield of Tennessee, collaborating primarily with providers and facilities submitting prior authorization requests, and supporting utilization management activities such as pre-certifications, appeals, and retrospective reviews.
- • The position offers opportunities to develop expertise in clinical utilization management, strengthen decision-making in high-pressure environments, enhance communication and collaboration with medical and administrative teams, and gain deep familiarity with healthcare regulations, accreditation standards (URAC, NCQA, CMS), and insurance benefit interpretation.
🎯 Requirements
- • Active Registered Nurse (RN) license in Tennessee or via the Nurse Licensure Compact
- • Minimum 3 years of clinical experience
- • Proficiency in Microsoft Office (Outlook, Word, Excel, PowerPoint)
🏖️ Benefits
- • Monday–Friday, 8:00–5:00 schedule with some flexibility
- • Opportunity to work remotely
- • Collaboration with healthcare providers and internal clinical teams to support appropriate care delivery
Skills & Technologies
About BlueCross BlueShield of Tennessee
BlueCross BlueShield of Tennessee is the largest health-benefit plan company headquartered in the state, providing medical, dental, vision, and Medicare Advantage coverage to individuals, employers, and government programs. Founded in 1945 as a nonprofit mutual insurance company, it administers benefits for more than 3 million members through statewide provider networks, care-management programs, and digital health services. The company also engages in community health initiatives, preventive-care outreach, and value-based reimbursement models to improve outcomes and manage costs across Tennessee.
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