Clinical Review Manager (Healthcare)

TL;DR

Clinical Review Manager (Healthcare): Conducting comprehensive clinical reviews of medical service requests and supporting utilization management activities with an accent on clinical judgment and contractual guidelines. Focus on pre-certifications, appeals, and retrospective reviews to ensure compliance with clinical standards and policies.

Location: Must be based in the USA (Chattanooga, TN or Remote)

Company

hirify.global is a major health insurance provider dedicated to serving members through comprehensive clinical standards and quality care coordination.

What you will do

• Conduct comprehensive clinical reviews of medical service requests using established criteria.
• Support utilization management activities including pre-certifications, appeals, and retrospective reviews.
• Collaborate with the Medical Director on escalated cases and facilitate care coordination through referrals.
• Interpret benefits, contract language, and medical policy criteria to ensure accurate review outcomes.
• Assist non-clinical staff in the performance of administrative reviews.
• Prioritize urgent or escalated cases while meeting strict turnaround-time deadlines.

Requirements

• Registered Nurse (RN) with an active license in Tennessee or a state participating in the Nurse Licensure Compact Law.
• 3 years of clinical experience.
• Working knowledge of URAC, NCQA, and CMS accreditations.
• Proficiency in Microsoft Office (Outlook, Word, Excel, PowerPoint).
• Ability to pass a Windows navigation test.
• Strong interpersonal, organizational, and problem-solving skills.

Culture & Benefits

• Standard Monday–Friday, 8:00–5:00 schedule with some flexibility.
• Collaborative, team-oriented work environment.
• Opportunity to work in an independent and creative manner.
• Commitment to equal employment opportunity and diversity.