Manages all aspects of clinical management, including program development, policy development, and regulatory and accreditation compliance. Oversee Clinical Management functions, which includes pre-authorization, pre-determination, retro review, denials and appeals, pre-existing reviews, and care management activities.
Job Description:
Job Responsibilities

• Providing clinical expertise in the development of programs and educational material pertaining to clinical management; providing guidance to staff who work directly on the programs.
• Participating in the development of effective strategies, policies, and procedures related to clinical management programs.
• Developing and implementing clinical programs to achieve improved rates, the highest accreditation, and improvement in the health of the population.
• Managing a team(s) of clinical staff to assure effectiveness of programs and appropriate professional evaluation of clinical services.
• Regular overnight travel is not required, but may be requested on occasion.

Job Qualifications
Experience

• 3 years - Utilization Management, or Case Management experience required
• 5 years - Experience in the Health Insurance Industry
• 3 years - Experience in management or supervisory/team lead capacity.

Skills/Certifications

• Extensive knowledge of all aspects of Utilization Management, Care Management, and Behavioral Health.

License

• If a Registered Nurse (RN) must have an active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law or the ability to secure the license immediately upon selection

Job Specific Requirements:
- UM experience highly preferred
- This posting is for 2 openings on the team.
Preferred Skills:
Number of Openings Available:
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
Applying for this job indicates your acknowledgement and understanding of the following statements:
BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, 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 found by reviewing the following page:
BCBST's EEO Policies/Notices
BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.
Tobacco-Free Hiring Statement
To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee 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, patch, lozenges and electronic or smokeless cigarettes) in any form 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. All offers of employment will be contingent upon passing a background check 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 check 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.