Clinical Director jobs at Prime Therapeutics - 606 jobs

Your Role The Clinical Program Manager, Principal in collaboration with the Regional Medical Director and the CMO Team for Commercial Business will be responsible for collaborating with all internal stakeholders and externally facing partners to transform the way health care is delivered, ensuring best-in-class care for all members. Priority is given to delivering on the Quadruple Aim (lower cost care, increased quality, increased member satisfaction and physician satisfaction) with a focus on execution to drive and accelerate improvements in primary care for all patients. This role will report to the Regional Medical Director. Your Knowledge and Experience Requires a current, active California RN, NP, or PA license Requires a bachelor's degree; advanced degree is preferred Requires a minimum of 10 years of prior relevant clinical or job related experience Requires previous health plan experience with understanding of Accountable Care Organizations (ACO), global versus shared risk financial arrangements, quality metrics and member experience. Experience in case utilization and utilization management and managed care delegated models is a plus. In-depth understanding of data analytics with mastery of excel and an ability to use multiple data platforms for internal and external communication. Strong PowerPoint application skills to create executive summaries and presentation decks. Excellent verbal and written communication style to drive positive outcomes Ability to be resourceful and collaborative; a team collaborator with strong listening skills and the ability to offer creative solutions to drive consensus. Your work: In this role, you will: Operate at a strategic business level to ensure projects/programs are in line with Blue Shield of California's strategic goals Consult with all levels (including senior management) making recommendations and influencing decision-making Leverage cross-functional internal and external relationships to drive initiatives forward Plan and implement multiple and extremely complex projects/programs spanning across business areas Determine key business issues, develop effective action plans, and implement to successful conclusion Perform data analysis for all lines of business: Analyze data in collaboration with Regional Medical Director for trends, drivers, and key initiatives. Incorporate the analysis into meaningful discussions with Group/IPA Identify opportunities around utilization, quality, and clinical initiatives: Work side by side with internal and external partners in the design and launch of clinical programs focused on high-risk members, hospital initiatives, and behavioral health as well as internal innovation programs Partner with medical groups to co-create programs encompassing a full spectrum of initiatives around disease management, complex care management, transitions of care and site of service, ensuring optimal utilization, access, and quality of care for members Lead with a collaborative approach and an understanding of existing resources and relationships between/among partner organizations while moving them towards constructive change Work cross functionally with Blue Shield of California internal teams to provide support both ad hoc and for recurrent initiatives

The Commercial team is hiring a **Clinical Review Manager** to support the Commercial lines of business through BlueCross BlueShield of Tennessee\. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as pre‑certifications, appeals, and retrospective reviews\. The Clinical Review Nurse applies sound clinical judgment and contractual guidelines to promote appropriate care, collaborates with the Medical Director on escalated cases, facilitates care coordination through referrals, and supports administrative review processes to ensure compliance with clinical standards and policies\. If this opportunity aligns with your experience and interests, we encourage you to apply\! **What We're Looking For \(In Addition to Required Qualifications\):** Preference for candidates who bring: + Strong **computer comfort and technical aptitude** + A collaborative, **team‑oriented** approach + **Flexibility** and adaptability + A positive attitude and willingness to learn **Typical Schedule** Our team primarily follows a **Monday-Friday, 8:00-5:00** schedule with some flexibility\. **Who You'll Work With** This role partners mainly with: + **Providers and facilities** who submit prior authorization requests **What Your Day‑to‑Day Looks Like** Your daily focus includes: + Reviewing cases in strict **turnaround‑time order** + Meeting required deadlines on cases + Prioritizing urgent or escalated cases as assigned by leadership + Ensuring each review is completed accurately, efficiently, and in alignment with clinical and contractual standards **Job Responsibilities** + Initiate referrals to ensure appropriate coordination of care\. + Seek the advice of the Medical Director when appropriate, according to policy\. + Assists non\-clinical staff in performance of administrative reviews + 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\. + Occasional weekend work may be required\. + Must be able to pass Windows navigation test\. + Testing/Assessments will be required for Digital positions\. + Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions\. **Job Qualifications** _License_ + Registered Nurse \(RN\) with 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\. _Experience_ + 3 years \- Clinical experience required _Skills\\Certifications_ + Proficient in Microsoft Office \(Outlook, Word, Excel and PowerPoint\) + Working knowledge of URAC, NCQA and CMS accreditations + Must be able to work in an independent and creative manner\. + Excellent oral and written communication skills + Strong interpersonal and organizational skills + Ability to manage multiple projects and priorities + Adaptive to high pace and changing environment + Customer service oriented + Superior interpersonal, client relations and problem\-solving skills + Proficient in interpreting benefits, contract language specifically symptom\-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria **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 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\.** As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945\. More than that, we're your neighbors and friends - fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow\. At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members\. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability\. We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously\. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST\. BCBST is a remote\-first organization with many employees working primarily from their homes\. Each position within the company is classified as either fully remote, partially remote, or office based\. BCBST hires employees for remote positions from across the U\.S\. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York\. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense\.If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance\.

Are you passionate about making a meaningful impact on the lives of individuals facing mental health challenges, while working behind the scenes? If so, **Utilization Management** might be the perfect fit for you\! In this role, you'll play a critical part in shaping care decisions and improving outcomes, all without direct, face\-to\-face interaction\. **What You'll Do** + Apply your knowledge of **Behavioral Health** and **Withdrawal Management diagnoses** \. + Navigate the **continuum of care** and levels of care for Behavioral Health and Withdrawal Management\. + Present cases confidently and effectively during clinical rounds\. + Work independently with minimal supervision\. + Excel in a **fast\-paced, dynamic environment** \. **Our Ideal Candidates will have an RN or Social Work license and:** + **3 years** \- Clinical behavioral health / substance use disorder experience required + **1 year** \- Must be knowledgeable about community care resources and levels of behavioral health care available\. **Along with** : + **3\+ years** of experience in **Psychiatric and/or Substance Use** treatment\. + Background in **Behavioral Health settings** \(both inpatient and outpatient\)\. + Prior experience in **Utilization Management** or **Managed Care** \. + Strong **communication and presentation skills** \. + Ability to work autonomously and manage time effectively\. + Adaptability and resilience in a rapidly changing work environment\. **Why Choose Us?** This is more than a job; it's an opportunity to make a lasting difference in people's lives while leveraging your expertise in a collaborative, supportive setting\. **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:** BCBST BlueCross BlueShield of Tennessee, 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\.** As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945\. More than that, we're your neighbors and friends - fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow\. At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members\. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability\. We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously\. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST\. BCBST is a remote\-first organization with many employees working primarily from their homes\. Each position within the company is classified as either fully remote, partially remote, or office based\. BCBST hires employees for remote positions from across the U\.S\. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York\. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense\.If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance\.

Logistics: Palmetto GBA - a subsidiary of BlueCross BlueShield of South Carolina Location: This remote position is full-time (40-hours/week) Monday-Friday. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. Until your enrollment is complete, you will receive supplemental pay for health coverage. Your coverage begins on the first day of the month following 28 days of full-time employment. Sponsorship: This position is not eligible for sponsorship now or in the future. Position Purpose: Provides supervision and direction of the statistical reporting function and data analysis to support clinical reporting function. What You'll Do: Monitors adherence to statistical reporting requirements, updates systems as necessary. Sets and maintains general direction/focus of statistical reporting function. Perform analysis and reporting including performing clinical trend analysis. Develop reports through various data reporting tools. Develop data driven solutions to improve outcomes. Collaborate with other areas to reduce expense through data analysis, including gathering business requirements, documentation, testing, and delivery of reporting. Serve as internal subject matter expert and point of contact for query/design for clinical analysis. Identifies data analysis needs based on customer. Supervises staff including directing work, addressing performance, and providing training. Review work and coach subordinates. Values: Consistently demonstrates high standards of integrity by supporting the Company's mission and values and adhering to the Corporate Code of Conduct. Confidentiality: Maintains high regard for member, customer and/or beneficiary privacy in accordance with the corporate confidentiality, privacy and security policies and procedures. Work Environment: Typical office environment. Some travel between office buildings. To Qualify for This Position, You'll Need: Required Education: Associate's degree Required Work Experience: 5 years of experience in healthcare data analysis and data retrieval Skills and Abilities: Strong written and verbal communication skills Strong analytical, judgment, presentation, critical thinking, organizational and planning skills Working knowledge of statistical concepts, population statistical and analysis methods. Comprehensive understanding of statistical principles and practices. Strong decision-making, reasoning and mathematical skills. Effectively direct and coordinate multiple tasks. Able to effectively manage complex project incorporating participation from key personnel across various areas of the company. Basic knowledge of accounting principles. Software and Other Tools: Proven experience with database query/reporting tools, software and other applications, such as Access Databases, DB2, SQL, and Easytrieve. Strong understanding of relational database structures, theories, principles, and practices with exposure to the analysis of relational database software and data retrieval methodologies. We Prefer that You Have: Medicare and Palmetto GBA experience. Bachelor's Degree 6 years of experience in healthcare data analysis and data retrieval Analytical, attention to detail Database, Microsoft, attracting format experience, spreadsheet diagram, reporting What we Can Do for You: Our comprehensive benefits package includes: 401(k) retirement savings plan with company match Subsidized health plans and free vision coverage Life insurance Paid annual leave - the longer you work here, the more you earn. Nine paid holidays On-site cafeterias and fitness centers in major locations Wellness programs and a healthy lifestyle premium discount Tuition assistance Service recognition What to Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify with prioritization given to those candidates who demonstrate the preferred qualifications. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email ************************ or call ************, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

The Commercial team is hiring a Clinical Review Manager to support the Commercial lines of business through BlueCross BlueShield of Tennessee. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as pre‑certifications, appeals, and retrospective reviews. The Clinical Review Nurse applies sound clinical judgment and contractual guidelines to promote appropriate care, collaborates with the Medical Director on escalated cases, facilitates care coordination through referrals, and supports administrative review processes to ensure compliance with clinical standards and policies. If this opportunity aligns with your experience and interests, we encourage you to apply! What We're Looking For (In Addition to Required Qualifications): Preference for candidates who bring: Strong computer comfort and technical aptitude A collaborative, team‑oriented approach Flexibility and adaptability A positive attitude and willingness to learn Typical Schedule Our team primarily follows a Monday-Friday, 8:00-5:00 schedule with some flexibility. Who You'll Work With This role partners mainly with: Providers and facilities who submit prior authorization requests What Your Day‑to‑Day Looks Like Your daily focus includes: Reviewing cases in strict turnaround‑time order Meeting required deadlines on cases Prioritizing urgent or escalated cases as assigned by leadership Ensuring each review is completed accurately, efficiently, and in alignment with clinical and contractual standards Job Responsibilities Initiate referrals to ensure appropriate coordination of care. Seek the advice of the Medical Director when appropriate, according to policy. Assists non-clinical staff in performance of administrative reviews 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. Occasional weekend work may be required. Must be able to pass Windows navigation test. Testing/Assessments will be required for Digital positions. Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions. Job Qualifications License Registered Nurse (RN) with 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. Experience 3 years - Clinical experience required Skills\Certifications Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) Working knowledge of URAC, NCQA and CMS accreditations Must be able to work in an independent and creative manner. Excellent oral and written communication skills Strong interpersonal and organizational skills Ability to manage multiple projects and priorities Adaptive to high pace and changing environment Customer service oriented Superior interpersonal, client relations and problem-solving skills Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria 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 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.

Are you passionate about making a meaningful impact on the lives of individuals facing mental health challenges, while working behind the scenes? If so, Utilization Management might be the perfect fit for you! In this role, you'll play a critical part in shaping care decisions and improving outcomes, all without direct, face-to-face interaction. What You'll Do Apply your knowledge of Behavioral Health and Withdrawal Management diagnoses. Navigate the continuum of care and levels of care for Behavioral Health and Withdrawal Management. Present cases confidently and effectively during clinical rounds. Work independently with minimal supervision. Excel in a fast-paced, dynamic environment. Our Ideal Candidates will have an RN or Social Work license and: 3 years - Clinical behavioral health / substance use disorder experience required 1 year - Must be knowledgeable about community care resources and levels of behavioral health care available. Along with: 3+ years of experience in Psychiatric and/or Substance Use treatment. Background in Behavioral Health settings (both inpatient and outpatient). Prior experience in Utilization Management or Managed Care. Strong communication and presentation skills. Ability to work autonomously and manage time effectively. Adaptability and resilience in a rapidly changing work environment. Why Choose Us? This is more than a job; it's an opportunity to make a lasting difference in people's lives while leveraging your expertise in a collaborative, supportive setting. 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: BCBST BlueCross BlueShield of Tennessee, 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.

Are you passionate about making a meaningful impact on the lives of individuals facing mental health challenges, while working behind the scenes? If so, **Utilization Management** might be the perfect fit for you\! In this role, you'll play a critical part in shaping care decisions and improving outcomes, all without direct, face\-to\-face interaction\. **What You'll Do** + Apply your knowledge of **Behavioral Health** and **Withdrawal Management diagnoses** \. + Navigate the **continuum of care** and levels of care for Behavioral Health and Withdrawal Management\. + Present cases confidently and effectively during clinical rounds\. + Work independently with minimal supervision\. + Excel in a **fast\-paced, dynamic environment** \. **Our Ideal Candidates will have an RN or Social Work license and:** + **3 years** \- Clinical behavioral health / substance use disorder experience required + **1 year** \- Must be knowledgeable about community care resources and levels of behavioral health care available\. **Along with** : + **3\+ years** of experience in **Psychiatric and/or Substance Use** treatment\. + Background in **Behavioral Health settings** \(both inpatient and outpatient\)\. + Prior experience in **Utilization Management** or **Managed Care** \. + Strong **communication and presentation skills** \. + Ability to work autonomously and manage time effectively\. + Adaptability and resilience in a rapidly changing work environment\. **Why Choose Us?** This is more than a job; it's an opportunity to make a lasting difference in people's lives while leveraging your expertise in a collaborative, supportive setting\. **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:** BCBST BlueCross BlueShield of Tennessee, 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\.** As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945\. More than that, we're your neighbors and friends - fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow\. At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members\. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability\. We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously\. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST\. BCBST is a remote\-first organization with many employees working primarily from their homes\. Each position within the company is classified as either fully remote, partially remote, or office based\. BCBST hires employees for remote positions from across the U\.S\. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York\. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense\.If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance\.

About Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi , the industry's leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform. Together with our clients, we're rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit **************** Location: Remote (For Non-Local) or Hybrid (Local to NYC area) Position Responsibilities: Oversee a dynamic team of pharmacy technicians engaged in the prior authorization process. Analyze available data to provide prior authorization staffing, workflow, and system enhancement recommendations to maximize team agility and performance. Actively participate in the prior authorization technician metric and quality goal setting process. Generate and deliver comprehensive reports on prior authorization technician metrics to both internal and external stakeholders. Assist the talent acquisition team in the hiring, evaluation, training, and onboarding of new employees. Investigate/resolve escalated issues or problems from team members, clients, and other internal teams. Key stakeholder in ensuring the prior authorization review platform is optimized for technician functions. Maintain relationships with external Independent Review Organizations and clinical resource vendors. Support the training and growth of both new and existing staff members in adherence to proper procedures. Collaborate with prior authorization leadership to develop process improvements and support long-term business needs, recommend new approaches, policies, and procedures to influence continuous improvements in department's efficiency and help establish best practices for conflict resolution while actively participating in problem identification and coordinate resolutions between appropriate parties. Assists with in other responsibilities, projects, implementations, and initiatives as needed in accordance with the policies and procedures established within the department. Prepare prior authorization requests received by validating prescriber and member information, level of review, and appropriate clinical guidelines. Maintain compliance with local, state, and federal laws, in addition to established organizational standards. Proactively obtains clinical information from prescribers, referral coordinators, and appropriate staff to ensure all aspects of clinical guidelines are addressed for pharmacist review. Triage phone calls from members, pharmacy personnel, and providers by asking applicable drug and client specific clinical questions. Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and Company policies Required Qualifications: Active, unrestricted, National Certified Pharmacy Technician (CPhT) license required Bachelor's or Associate's degree is preferred 4+ years of PBM or Managed Care pharmacy experience required Proficient in Microsoft Office Suite with emphasis on Microsoft Excel and PowerPoint Strong clinical background required Excellent communication, writing, and organizational skills Ability to multi-task and collaborate in a team with shifting priorities Preferred Qualifications: 2+ years of regulated market prior authorization operations experience or knowledge of how to operationalize regulated market requirements Previous prior authorization operations leadership experience Salary Range$80,000-$90,000 USD All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals. Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at *********************************************

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. The Clinical Vendor Program Manager role is responsible for the vendor oversight and delivery of a delegated Utilization Management program. This role works closely with the Clinical Vendor Oversight Manager to ensure compliance with contractual obligations, regulatory requirements, and organizational standards. The Clinical Vendor Program Manager serves as the primary liaison between the organization and the Utilization Management vendor driving performance, quality, and affordability initiative success to meet and support Medica's mission, vision and desired outcomes. Performs other duties as assigned. Key Accountabilities Vendor Oversight and Compliance Act as the main point of contact for the vendor relationship to support a delegated clinical program and affordability initiative Vendor Performance & Accountability: Monitor vendor adherence to contractual terms, maintain service level agreement (SLA) documentation and budget management Identify opportunities within the program and implement corrective action and remediation plans when necessary Partner with Clinical Regulatory Oversight Program Manager to maintain regulatory compliance and deliverables Ensure timely submission of reports and deliverables as outlined in Statements of Work (SOW) Program Management, Collaboration & Communication Manage cross-functional relationships between IT and Business Partners to include but not limited to: Provider Network, Internal Utilization Management, Provider Data and Eligibility Teams, Claims, Customer Service and Account Management to support program success Oversee affordability measures and outcome monitoring Drive regular meetings with vendors and internal stakeholders to ensure program success Facilitate complex conversations with vendors to achieve Medica's desired outcomes Provide updates to leadership on vendor performance, risks, and mitigation strategies Required Qualifications Bachelor's degree or equivalent experience in related field 7+ years of related experience beyond degree Skills and Abilities Experience in vendor management, and clinical delegated vendor oversight strongly preferred Computer proficiencies including Microsoft Office (Word, Excel, Access, Outlook, Visio, OneNote, etc.) and experience with others. Program functions (workflow, eligibility, claims, etc.) Ability to lead and be a good role model, influence change, shape and initiate work with colleagues across the organization and external (care systems, community collaborations, and vendors) to achieve department goals Ability to provide leadership based on teamwork, commitment & creative linkages with organizational business units, external vendors and care system representatives Excellent written and verbal communication skills with all levels of the organization Managing/Delegating/Measuring Work: Ability to develop appropriate objectives, accountabilities and measures. Ability to monitor and report progress; identify and address barriers Quality Focus: Commitment to continuous quality improvement in all aspects of work. Skilled user of quality tools and techniques Experience setting expectations and direction for delivery by the team This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, or Madison, WI. The full salary grade for this position is $88,800 - $152,300. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $88,800 - $133,245. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data.  In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees. The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law. Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

RWS CRITERIA-BASED JOB DESCRIPTION TITLE: Clinical Director RESPONSIBLE TO: Operations The Clinical Director is responsible for the supervision of a clinical team in our outpatient behavioral health facilities including Nurse Practioner, Therapists, and Field Staff. You will maintain standards of professional counseling practice in accordance with clinic policies and procedures. The Clinical Director is responsible for directing care of patients, facilitating workflows, and serving as a resource for staff and for providing team leadership and direction alongside the Regional Director and Operations team. Responsibilities Provide direct supervision of clinical staff including Therapists, Counselors, and Case Managers, and ensure compliance with state and federal regulations, Medicaid standards, CARF standards, and clinic and corporate policies and procedures; Make staff assignments and create schedules; update support staff when changes are made; Monitor clinician's compliance with productivity requirements and develop, design, implement and execute a quality improvement program, training all Therapists, Counselors, and Case Managers at orientation and on an as needed and ongoing basis; Ensure quality patient care; conduct treatment plan reviews and client service surveys on a regular basis; Maintain strict compliance with HIPAA guidelines and confidentiality; Perform chart audits and communicate results of audits to staff; Assess levels of care for patients; conduct treatment plan reviews as required; Provide direct clinical services to individuals and families within your professional scope of practice as necessary to deliver timely care to clients in need; Meet consistently, one-on-one, with each member of your team to discuss client services provided, employee concerns, provide training and support and identify opportunities for the professional growth of each team member; Assist with the recruitment, hiring, and training of qualified clinical staff; May also be involved in crisis intervention and work as a liaison within community; Serve as an advocate for direct reports and clients, providing support and identifying additional opportunities to assist both parties; Work directly with Regional Site Manager and Corporate office to account for operations of clinical staff, identify needs, and ensure top performance; Ensure ethical and professional conduct by clinical staff; and, Perform other duties as assigned Qualifications Your Skills and Qualifications as a Clinical Director: Master's Degree in behavioral health field and a minimum of 5 years clinical experience; Must be able to perform supervisory responsibilities with supervisory experience in an outpatient facility setting or health or human service agency, one year of which was working directly with behavioral health population LPC/LPC-S, LMFT/LMFT-S or LCSW/LCSW-S licensure required; Minimum of 2 years operations/management experience; Requires excellent interpersonal skills and professional communication style; Must pass all federal and state background checks. Education and work history will be confirmed in compliance with company policies Licenses/Certifications: Clinical certification as required by the state in which the clinic operates if applicable.

✨Join a group of passionate advocates on our mission to improve the lives of youth! Rite of Passage Team is hiring for a Assistant Clinical Director at Cypress Creek Youth Academy, in Lecanto, FL ✨ Cypress Creek is a residential commitment program located in Citrus County Florida. It serves high-risk and max-risk youth ages 15 to 21. The goal of the program is to provide services utilize evident-based practices to provide comprehensive care, treatment and supervision. We offer clinical supervision to qualified applicants. Performance Based Compensation reviews are conducted annually (2%,4%, or 6%) Eligible for Medical, Dental, Vision, and Life Insurance (at 60 days for Hourly employees and 90 days for Salaried) Choice of Supplemental benefits, including Short Term Disability and increased Life Insurance. Eligible for 100% 401k match of up to 6% of your salary after 1 year of employment. Paid Time Off that can be used as soon as it accrues. ************************************************* ROP-benefits-and-perks-2 The Clinical Supervisor works as the primary supervisor of the Clinical Team. Primarily responsible for all clinical functions to ensure that treatment continuity is maintained for students and families. The Clinical Supervisor reports to the Clinical Director or Program Director. In some instances, may supervise designated staff. Masters Degree in Psychology, Family Therapy or Social Work with current state licensure. Licensure must be maintained with photocopies on file. Prior clinical and administrative experience in a residential setting, and a background in working with adolescent offenders and their families is preferred. Rite of Passage is a leading national provider of programs and opportunities for troubled and at-risk youth from social services, welfare agencies and juvenile courts. With an emphasis on evidence-based practices and positive skill development, combined with our supportive and therapeutic approach, our organization is respected by industry experts as a highly effective solution for our youth. Since 1984, over 70,000 youths have entered and completed our programs. ROP has built its reputation on running life-changing educational treatment programs that positively contribute to the community. Apply today and Make a Difference in the Lives of Youth! After 40 years of improving the lives of youth, we are looking for passionate advocates to continue the legacy of helping young people become successful adults. As a Assistant Clinical Director, you will have the unique opportunity to create a positive, safe and supportive environment for the youth we serve while building a career rich in growth opportunities and self-fulfillment. Follow us on Social! Instagram / Facebook / Linkedin / Tik Tok / YouTube

Your Role The Clinical Program Manager, Principal in collaboration with the Regional Medical Director and the CMO Team for Commercial Business will be responsible for collaborating with all internal stakeholders and externally facing partners to transform the way health care is delivered, ensuring best-in-class care for all members. Priority is given to delivering on the Quadruple Aim (lower cost care, increased quality, increased member satisfaction and physician satisfaction) with a focus on execution to drive and accelerate improvements in primary care for all patients. This role will report to the Regional Medical Director. Responsibilities Your work In this role, you will: Operate at a strategic business level to ensure projects/programs are in line with Blue Shield of California's strategic goals Consult with all levels (including senior management) making recommendations and influencing decision-making Leverage cross-functional internal and external relationships to drive initiatives forward Plan and implement multiple and extremely complex projects/programs spanning across business areas Determine key business issues, develop effective action plans, and implement to successful conclusion Perform data analysis for all lines of business: Analyze data in collaboration with Regional Medical Director for trends, drivers, and key initiatives. Incorporate the analysis into meaningful discussions with Group/IPA Identify opportunities around utilization, quality, and clinical initiatives: Work side by side with internal and external partners in the design and launch of clinical programs focused on high-risk members, hospital initiatives, and behavioral health as well as internal innovation programs Partner with medical groups to co-create programs encompassing a full spectrum of initiatives around disease management, complex care management, transitions of care and site of service, ensuring optimal utilization, access, and quality of care for members Lead with a collaborative approach and an understanding of existing resources and relationships between/among partner organizations while moving them towards constructive change Work cross functionally with Blue Shield of California internal teams to provide support both ad hoc and for recurrent initiatives Qualifications Your Knowledge and Experience Requires a current, active California RN, NP, or PA license Requires a bachelor's degree; advanced degree is preferred Requires a minimum of 10 years of prior relevant clinical or job related experience Requires previous health plan experience with understanding of Accountable Care Organizations (ACO), global versus shared risk financial arrangements, quality metrics and member experience. Experience in case utilization and utilization management and managed care delegated models is a plus. In-depth understanding of data analytics with mastery of excel and an ability to use multiple data platforms for internal and external communication. Strong PowerPoint application skills to create executive summaries and presentation decks. Excellent verbal and written communication style to drive positive outcomes Ability to be resourceful and collaborative; a team collaborator with strong listening skills and the ability to offer creative solutions to drive consensus

RWS CRITERIA-BASED JOB DESCRIPTION TITLE: Clinical Director RESPONSIBLE TO: Operations The Clinical Director is responsible for the supervision of a clinical team in our outpatient behavioral health facilities including Nurse Practioner, Therapists, and Field Staff. You will maintain standards of professional counseling practice in accordance with clinic policies and procedures. The Clinical Director is responsible for directing care of patients, facilitating workflows, and serving as a resource for staff and for providing team leadership and direction alongside the Regional Director and Operations team. Responsibilities Provide direct supervision of clinical staff including Therapists, Counselors, and Case Managers, and ensure compliance with state and federal regulations, Medicaid standards, CARF standards, and clinic and corporate policies and procedures; Make staff assignments and create schedules; update support staff when changes are made; Monitor clinician's compliance with productivity requirements and develop, design, implement and execute a quality improvement program, training all Therapists, Counselors, and Case Managers at orientation and on an as needed and ongoing basis; Ensure quality patient care; conduct treatment plan reviews and client service surveys on a regular basis; Maintain strict compliance with HIPAA guidelines and confidentiality; Perform chart audits and communicate results of audits to staff; Assess levels of care for patients; conduct treatment plan reviews as required; Provide direct clinical services to individuals and families within your professional scope of practice as necessary to deliver timely care to clients in need; Meet consistently, one-on-one, with each member of your team to discuss client services provided, employee concerns, provide training and support and identify opportunities for the professional growth of each team member; Assist with the recruitment, hiring, and training of qualified clinical staff; May also be involved in crisis intervention and work as a liaison within community; Serve as an advocate for direct reports and clients, providing support and identifying additional opportunities to assist both parties; Work directly with Regional Site Manager and Corporate office to account for operations of clinical staff, identify needs, and ensure top performance; Ensure ethical and professional conduct by clinical staff; and, Perform other duties as assigned Qualifications Your Skills and Qualifications as a Clinical Director: Master's Degree in behavioral health field and a minimum of 5 years clinical experience; Must be able to perform supervisory responsibilities with supervisory experience in an outpatient facility setting or health or human service agency, one year of which was working directly with behavioral health population LPC/LPC-S, LMFT/LMFT-S or LCSW/LCSW-S licensure required; Minimum of 2 years operations/management experience; Requires excellent interpersonal skills and professional communication style; Must pass all federal and state background checks. Education and work history will be confirmed in compliance with company policies Licenses/Certifications: Clinical certification as required by the state in which the clinic operates if applicable.

✨Join a group of passionate advocates on our mission to improve the lives of youth! Rite of Passage Team is hiring for a Clinical Director at Oak Grove Academy in Jasper, Florida. ✨ Located in rural Jasper, Florida - At Oak Grove Academy, we provide a therapeutic approach to improving the lives of Youth through the many opportunities we offer such as Equine, Sports, Culinary Arts, Medical and Masonry. Perks & Benefits: Medical, Dental, Vision and company paid Life Insurance within 90 days, and 401 K match up to 6% after 1 year of employment, Paid Time Off that can be used as soon as it accrues and more! ROP-benefits-and-perks-2 What you will do: The Clinical Director is primarily responsible for assessing student mental health needs, supervising the activities and staff that provide individual, group and family therapy, and monitoring students with mental illness and/or receiving psychotropic medications. To be considered you should: Be empathetic, patient, and treat others with respect. Must have a Masters Degree and a current state licensure in LCSW, LMFT, or LPC. Be at least 21 years of age. Have a desire to work with at-risk youth. Be able to pass a criminal background check, child abuse registry, drug screen, physical, and TB test. Schedule: 5 days on/2 days off, forty hours per week. Monday-Friday, however schedule may vary or be adjusted due to business demand or unforeseen circumstances. Apply today and Make a Difference in the Lives of Youth! After 40 years of improving the lives of youth, we are looking for passionate advocates to continue the legacy of helping young people become successful adults. As a Clinical Director , you will have the unique opportunity to create a positive, safe and supportive environment for the youth we serve while building a career rich in growth opportunities and self-fulfillment. Follow us on Social! Instagram / Facebook / Linkedin / Tik Tok / YouTube

At Dungarvin, we support people with intellectual and developmental disabilities to live as independently as possible through person-centered services rooted in respect, response, and choice. Founded in 1976, Dungarvin provides community-based supports across 15 states, united by a shared commitment to making a meaningful difference in people's lives. Lead behavioral services. Coach teams. See real impact in adult community programs. As a BCBA (Board Certified Behavior Analyst) Clinical Services Manager at Dungarvin, you will play a key role in shaping how behavioral services are delivered across our adult day programs in Fairfield and Vacaville. This role blends clinical expertise with leadership, giving you the opportunity to guide practice, support staff, and see the results of your work reflected in people's daily lives. You'll serve as a clinical leader for behavior services, supporting teams through complex behavioral needs and ensuring services are ethical, effective, and aligned with BACB standards and regulatory requirements. Rather than working in a clinic-only setting, you'll collaborate directly with program leaders and direct support professionals in real-world environments where your guidance has immediate, meaningful impact. BENEFITS: * Starting Salary: $106,449 / year * Full Wage Scale: $106,449 - $115,474.76 (Future increases within the posted range are based on tenure and performance per Dungarvin's compensation guidelines.) * Schedule: 8am - 5pm M-F * Medical, Vision and Dental Insurance * Supplemental Insurance * Flex Spending and HSA Account * Pet Insurance * Life Insurance * 401 K plan with up to 3% employer match based on eligibility requirements * Generous Paid Time Off (PTO) * Growth and Development Opportunities * Employee Referral Program * Employee Assistance Program * Paid training and orientation Job Description What You'll Do * Develop, implement, and oversee individualized behavior support plans using functional assessments, data-informed decision-making, and person-centered approaches. * Provide direct clinical services as needed, including behavioral assessments, consultation, and ongoing plan review. * Supervise, coach, and mentor behavioral staff, including Behavior Analysts, Behavior Specialists, Registered Behavior Technicians, and Direct Support Professionals. * Provide regular clinical guidance and feedback to support consistent, high-quality implementation of behavior support strategies. * Collaborate closely with program leadership and interdisciplinary teams to align clinical services with program needs. * Support staff in navigating complex behaviors while promoting safe, effective, and respectful interventions. * Promote independence, inclusion, and quality of life for individuals supported in community-based settings. Who This Role Is For This role is ideal for a BCBA who enjoys both clinical work and leadership, and who thrives in collaborative, community-based settings. You are someone who values person-centered care, feels confident supporting staff and complex cases, and wants to make a meaningful impact beyond a traditional clinic environment. If you enjoy building systems, mentoring others, and seeing your work translate directly into improved daily lives for the people you support, this role is a strong fit. Qualifications * Certification: Must be a Board Certified Behavior Analyst (BCBA), recognized by the Behavior Analyst Certification Board (BACB). * Experience: * 2 years of experience as a BCBA, specifically in developing and implementing behavior support plans. * 2 years of experience working with individuals with intellectual or developmental disabilities. * Supervisory experience preferred, including direction and development of Registered Behavior Technician and other clinical staff. * Education: Master's degree in Applied Behavior Analysis, Psychology, or a related field. * Skills: Strong communication (verbal and written), analytical, administrative, and organizational abilities. Must have effective listening and interpersonal skills to work both independently and collaboratively within a team. * Additional Requirements: A valid driver's license and auto insurance. Additional Information At Dungarvin, diversity and inclusion are a part of what makes our organization strong. Together, we can continue to work towards an inclusive culture that supports our employees and persons served. Compass and Dungarvin are an equal opportunity employer. #DCAJ #1/22

The Commercial team is hiring a Clinical Review Manager to support the Commercial lines of business through BlueCross BlueShield of Tennessee. This role conducts comprehensive clinical reviews of medical service requests using established criteria and supports utilization management activities such as pre‑certifications, appeals, and retrospective reviews. The Clinical Review Nurse applies sound clinical judgment and contractual guidelines to promote appropriate care, collaborates with the Medical Director on escalated cases, facilitates care coordination through referrals, and supports administrative review processes to ensure compliance with clinical standards and policies. If this opportunity aligns with your experience and interests, we encourage you to apply! What We're Looking For (In Addition to Required Qualifications): Preference for candidates who bring: Strong computer comfort and technical aptitude A collaborative, team‑oriented approach Flexibility and adaptability A positive attitude and willingness to learn Typical Schedule Our team primarily follows a Monday-Friday, 8:00-5:00 schedule with some flexibility. Who You'll Work With This role partners mainly with: Providers and facilities who submit prior authorization requests What Your Day‑to‑Day Looks Like Your daily focus includes: Reviewing cases in strict turnaround‑time order Meeting required deadlines on cases Prioritizing urgent or escalated cases as assigned by leadership Ensuring each review is completed accurately, efficiently, and in alignment with clinical and contractual standards Job Responsibilities Initiate referrals to ensure appropriate coordination of care. Seek the advice of the Medical Director when appropriate, according to policy. Assists non-clinical staff in performance of administrative reviews 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. Occasional weekend work may be required. Must be able to pass Windows navigation test. Testing/Assessments will be required for Digital positions. Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions. Job Qualifications License Registered Nurse (RN) with 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. Experience 3 years - Clinical experience required Skills\Certifications Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) Working knowledge of URAC, NCQA and CMS accreditations Must be able to work in an independent and creative manner. Excellent oral and written communication skills Strong interpersonal and organizational skills Ability to manage multiple projects and priorities Adaptive to high pace and changing environment Customer service oriented Superior interpersonal, client relations and problem-solving skills Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria 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 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.

Are you passionate about making a meaningful impact on the lives of individuals facing mental health challenges, while working behind the scenes? If so, Utilization Management might be the perfect fit for you! In this role, you'll play a critical part in shaping care decisions and improving outcomes, all without direct, face-to-face interaction. What You'll Do Apply your knowledge of Behavioral Health and Withdrawal Management diagnoses. Navigate the continuum of care and levels of care for Behavioral Health and Withdrawal Management. Present cases confidently and effectively during clinical rounds. Work independently with minimal supervision. Excel in a fast-paced, dynamic environment. Our Ideal Candidates will have an RN or Social Work license and: 3 years - Clinical behavioral health / substance use disorder experience required 1 year - Must be knowledgeable about community care resources and levels of behavioral health care available. Along with: 3+ years of experience in Psychiatric and/or Substance Use treatment. Background in Behavioral Health settings (both inpatient and outpatient). Prior experience in Utilization Management or Managed Care. Strong communication and presentation skills. Ability to work autonomously and manage time effectively. Adaptability and resilience in a rapidly changing work environment. Why Choose Us? This is more than a job; it's an opportunity to make a lasting difference in people's lives while leveraging your expertise in a collaborative, supportive setting. 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: BCBST BlueCross BlueShield of Tennessee, 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.

Are you passionate about making a meaningful impact on the lives of individuals facing mental health challenges, while working behind the scenes? If so, Utilization Management might be the perfect fit for you! In this role, you'll play a critical part in shaping care decisions and improving outcomes, all without direct, face-to-face interaction. What You'll Do Apply your knowledge of Behavioral Health and Withdrawal Management diagnoses. Navigate the continuum of care and levels of care for Behavioral Health and Withdrawal Management. Present cases confidently and effectively during clinical rounds. Work independently with minimal supervision. Excel in a fast-paced, dynamic environment. Our Ideal Candidates will have an RN or Social Work license and: 3 years - Clinical behavioral health / substance use disorder experience required 1 year - Must be knowledgeable about community care resources and levels of behavioral health care available. Along with: 3+ years of experience in Psychiatric and/or Substance Use treatment. Background in Behavioral Health settings (both inpatient and outpatient). Prior experience in Utilization Management or Managed Care. Strong communication and presentation skills. Ability to work autonomously and manage time effectively. Adaptability and resilience in a rapidly changing work environment. Why Choose Us? This is more than a job; it's an opportunity to make a lasting difference in people's lives while leveraging your expertise in a collaborative, supportive setting. 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: BCBST BlueCross BlueShield of Tennessee, 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.

Job Description SUMMARY: Under the guidance of the Operations Team and Regional Leadership, the Clinical Manager oversees the Outpatient Behavioral Health Therapist Supervisors and Therapist/Clinical teams at Path Behavioral Healthcare. This role includes managing work schedules, assigning clients based on various factors, caseload management, reporting, and ensuring the delivery of appropriate care and services. The Clinical Manager is also responsible for orienting new therapists and providing necessary ongoing training. This position requires an unrestricted license to provide direct clinical services within their scope of practice, offering timely support to clients in need. The role involves various other duties as assigned to ensure operations run smoothly. DUTIES AND RESPONSIBILITIES: CLINICAL Provide direct supervision of Outpatient Behavioral Health Therapist Supervisors and Therapist teams, ensuring compliance with Medicaid, state licensing, and clinical requirements. Conduct monthly and as-needed one-on-one meetings and supervision with therapists. Ensure the quality and adherence of notes and documentation to compliance policies and standards. Guide therapists in client care, coordinating with Case Managers and treatment teams. Advocate for therapists and clients, offering support and intervening in crises. Provide direct clinical services within your professional scope as needed. Complete and/or review all client documentation accurately and timely according to organizational standards. ADMINISTRATIVE · Oversee service delivery, including pre-audit of billing charges and maintenance of client files. · Coordinate services and oversee staff scheduling and resource allocation in collaboration with Regional Leadership and Operations. · Assist in the implementation of the quality improvement program in conjunction with the CCO and QA Manager and COO, actively ensuring therapists receive comprehensive and ongoing training. · Participate in the hiring process and staff interviews in collaboration with HR and Regional Leadership. Ensure supervision logs for respective supervisors/supervisees are completed. Oversee completion of annual performance evaluations for all therapists and therapist supervisors. Oversee the training of all therapists and therapist supervisors including new hires with 2 intakes and 2 individual sessions within the first 90 days of employment and 1 intake and 1 individual session thereafter. Responsible for oversight and management of therapist caseloads, failed activities, clinical performance, and other administrative duties, either by direct supervision and management of therapist supervisors or direct supervision and management of therapists. Meet with community partners: i.e. schools, courts, etc. OTHER · Maintain an organized practice and adhere to scheduled work hours. · Ensure strict compliance with HIPAA guidelines and confidentiality agreements. · Attend required continuing education for licensure maintenance. Work professionally and collaboratively with Path Behavioral Healthcare employees, adhering to all organizational policies. Respect cultural diversity, religious, and personal values of clients and their families in line with Path's mission. · Maintain a positive professional demeanor, exemplifying Path's mission and vision. QUALIFICATIONS: Education: Master of Social Work or Clinical Counseling from an accredited university. Licensure: LISW-S and LPCC-S Experience: Minimum of 2 years operations/management experience Thorough knowledge of billing and coding guidelines Physical Effort: This position requires the ability to work under stressful conditions and to work irregular hours. Requires sitting for extended periods of time, viewing computer monitors, and keyboarding. Communication Skills: must possess excellent verbal and written communication skills in order to communicate professionally via telephone and in writing. Strong grammar and writing skills are crucial for clear and concise communication with clients, colleagues, and other healthcare professionals. Interpersonal Skills: The successful candidate must demonstrate the ability to interact and assist in a friendly, compassionate, and professional manner with colleagues, providers, clients, and their families, as they represent both themselves and Path Behavioral Healthcare. Essential Technical/Motor Skills: Candidates must achieve competency in the Electronic Health Record (EHR) program, telemedicine services, and any additional software programs utilized by the company, ensuring efficient access and updating of client information. The role requires fine dexterity, adept handling, and proficient gripping abilities to perform various tasks. Background: The candidate must pass all federal and state background checks, and their educational and work history will be confirmed in compliance with company policies.