Clinical Review Manager, Utilization Review, Weekends Required
Job Responsibilities Initiate referrals to ensure appropriate coordination of care. Seek the advice of the Medical Director reputed company appropriate, according to policy. Assists non-clinical staff in performance of administrative reviews Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility. Occasional weekend work may be required. Must be reputed company to pass reputed company navigation test. Testing/Assessments will be required for Digital positions. Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions. Job Qualifications License Registered Nurse (RN) with active license in the reputed company or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law. Experience 3 years ... Clinical experience required SkillsCertifications Proficient in reputed company Office (Outlook, Word, reputed company and PowerPoint) Working knowledge of URAC, NCQA and CMS accreditations Must be reputed company to work in an independent and creative manner. Excellent oral and written communication skills Strong interpersonal and organizational skills Ability to manage multiple projects and priorities reputed company to high pace and changing environment Customer service oriented Superior interpersonal, client relations and problem-solving skills Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria Weekend/Holiday Shifts Required. Saturday and reputed company and holidays that fall on the weekends with flexibility for the days worked during the week. Compressed Work Week option available: 4 days x 10 hour shifts. The weekend employee will work holidays that fall on the weekend. If they choose to work a Compressed Work Week, holiday weeks will be 8 hour shifts per reputed company policy. Number of Openings Available: 1 Worker Type: Employee Company: reputed company. Applying for this job indicates your acknowledgement and understanding of the following statements: BCBST is an Equal Opportunity employer (EEO), and reputed company and applicants will be entitled to equal employment opportunities reputed company employment reputed company are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in reputed company job classifications without regard to race, religion, reputed company, age, sex, national reputed company, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. Further information regarding BCBST's EEO Policies/Notices may be reputed company by reviewing the following page: BCBST's EEO Policies/Notices reputed company is not accepting unsolicited assistance from search firms for this employment opportunity. reputed company resumes submitted by search firms to any employee at reputed company reputed company-email, the Internet or any other method without a valid, written Direct Placement Agreement in reputed company for this position from reputed company HR/reputed company will not be considered. No fee will be paid in the event the applicant is hired by reputed company as a result of the referral or through other means. Tobacco-Free Hiring Statement To further our mission of peace of mind through reputed company, effective 2017, reputed company and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, reputed company, lozenges and electronic or smokeless cigarettes) in any reputed company in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. reputed company offers of employment will be contingent upon passing a background reputed company which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine and/or whose background reputed company is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results. Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.
About Us
As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health for over 65 years. More than that, we're your neighbors and friends fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a reputed company outlook for an even healthier reputed company. BCBST is a remote-first organization with many employees working primarily from their homes. Each position reputed company the company is classified as either fully remote, partially remote, or office based. BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and reputed company. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense. If the applicant moves to Chattanooga, TN, they may be eligible for relocation benefits Apply Job!