Behavioral Health Clinical Review Manager

TL;DR

Behavioral Health Clinical Review Manager (Medical): Managing clinical reviews and utilization management for behavioral health and substance use disorder cases with an accent on clinical judgment, medical appropriateness criteria, and care coordination. Focus on performing comprehensive appeals, pre-certifications, and ensuring high-quality care outcomes in a fast-paced environment.

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

Company

A leading health insurance provider dedicated to improving the health and well-being of Tennesseans.

What you will do

• Apply clinical knowledge to evaluate behavioral health and withdrawal management diagnoses.
• Perform utilization management tasks including pre-certifications, appeals, and retrospective claim reviews.
• Coordinate care and initiate referrals based on medical appropriateness criteria.
• Present clinical cases effectively during rounds and collaborate with Medical Directors.
• Assist non-clinical staff with administrative reviews and ensure contractual eligibility.

Requirements

• Current, active unrestricted Tennessee license in Nursing (RN) or behavioral health field (Master's level or above).
• 3+ years of clinical experience in behavioral health or substance use disorder treatment.
• 1+ year of experience with community care resources and levels of behavioral health care.
• Prior experience in Utilization Management or Managed Care.
• Proficiency in Microsoft Office suite.
• Strong analytical, communication, and presentation skills.

Culture & Benefits

• Opportunity to make a meaningful impact on patient outcomes in a supportive, collaborative environment.
• Focus on professional growth and leveraging clinical expertise in a non-direct care setting.
• Comprehensive corporate benefits package.
• Dynamic and fast-paced work environment.