Behavioral Health Clinical Review Manager - UM

Join Our Team as a Behavioral Health Clinical Review Manager!
Are you a licensed Behavioral Health Clinician or RN with at least 3 years of hands-on psychiatric clinical experience? Our Behavioral Health Utilization Management team is looking for a dedicated professional like you to help ensure members receive the care they need.

In this role, you’ll review inpatient and outpatient behavioral health treatment requests across all age groups, using your clinical expertise to support quality care decisions.

We’re seeking candidates with a strong background in psychiatric or substance use treatment settings. Prior experience in utilization management is a plus. This is a fully phone-based position with consistent coverage required during your shift—Monday through Friday, either 8 AM–5 PM or 9 AM–6 PM ET.

You’ll collaborate with external providers across Medicaid and Medicare lines of business, helping to identify and remove barriers to care. At BlueCross BlueShield of Tennessee, we pride ourselves on teamwork, strong provider relationships, and a shared commitment to improving mental health outcomes.

Success in this role starts with excellent communication, solid clinical judgment, strong computer skills, and the ability to work independently in a fast-paced environment.

This is a fully remote role but candidates must reside in the state of Tennessee

Job 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.

Job Qualifications

License

• 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. RN may hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Experience

• 3 years - Clinical behavioral health / substance use disorder experience required

Skills\Certifications

• 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

Number of Openings Available:

1

Worker Type:

Employee

Company:

VSHP Volunteer State Health Plan, Inc

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will 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.