Note: The job is a remote job and is open to candidates in USA. BlueCross BlueShield of Tennessee is seeking a Behavioral Health Clinical Review Manager to play a critical role in shaping care decisions and improving outcomes for individuals facing mental health challenges. The ideal candidate will apply their knowledge in Behavioral Health and Withdrawal Management, working independently in a fast-paced environment.
Responsibilities
- Assists non-clinical staff in performance of administrative reviews
- Initiate referrals to ensure appropriate coordination of care
- Seek the advice of the Medical Director when appropriate, according to policy
- 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
- Various immunizations and/or associated medical tests may be required for this position
Skills
- Current, active unrestricted Tennessee license in Nursing (RN) or behavioral health field (Master's level or above) (Ph.D., LCSW/LMSW, LLP, MHC, LPC, etc.) required
- 3 years - Clinical behavioral health / substance use disorder experience required
- Must be knowledgeable about community care resources and levels of behavioral health care available
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Independent, Sound decision-making and problem-solving skills
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
- Strong analytical skills
- Positive relationship building skills and ability to engage with diverse populations
- Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions
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