Qureos Mentor

BlueCross BlueShield of Tennessee

<div>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&rsquo;re Looking For (In Addition to Required Qualifications):
Preference for candidates who bring:<ul><li>
Strong computer comfort and technical aptitude</li><li>
A collaborative, team‑oriented approach</li><li>
Flexibility and adaptability</li><li>
A positive attitude and willingness to learn</li></ul>
Typical Schedule
Our team primarily follows a Monday&ndash;Friday, 8:00&ndash;5:00 schedule with some flexibility.
Who You&rsquo;ll Work With
This role partners mainly with:<ul><li>
Providers and facilities who submit prior authorization requests</li></ul>
What Your Day‑to‑Day Looks Like
Your daily focus includes:<ul><li>
Reviewing cases in strict turnaround‑time order</li><li>
Meeting required deadlines on cases</li></ul><ul><li>
Prioritizing urgent or escalated cases as assigned by leadership</li><li>
Ensuring each review is completed accurately, efficiently, and in alignment with clinical and contractual standards</li></ul>
Job Responsibilities<ul><li>
Initiate referrals to ensure appropriate coordination of care.</li><li>
Seek the advice of the Medical Director when appropriate, according to policy.</li><li>
Assists non-clinical staff in performance of administrative reviews</li><li>
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.</li><li>
Occasional weekend work may be required.</li><li>
Must be able to pass Windows navigation test.</li><li>
Testing/Assessments will be required for Digital positions.</li><li>
Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.</li></ul>
Job Qualifications
License<ul><li>
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.</li></ul>
Experience<ul><li>
3 years - Clinical experience required</li></ul>
Skills\Certifications<ul><li>
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)</li><li>
Working knowledge of URAC, NCQA and CMS accreditations</li><li>
Must be able to work in an independent and creative manner.</li><li>
Excellent oral and written communication skills</li><li>
Strong interpersonal and organizational skills</li><li>
Ability to manage multiple projects and priorities</li><li>
Adaptive to high pace and changing environment</li><li>
Customer service oriented</li><li>
Superior interpersonal, client relations and problem-solving skills</li><li>
Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria</li></ul>
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.</div>

Clinical Review Manager

<div>As a Commercial Customer Service Trainee, you&rsquo;ll engage with members to handle customer service inquiries via the telephone. You&rsquo;ll be a great match for this position if you have experience with:<ul><li><div>
Customer service in retail, healthcare, insurance, call center or any other customer facing environment</div></li><li><div>
Receiving, investigating, and resolving customer inquiries using strong technical skills to deliver quick, effective solutions</div></li><li><div>
Working independently and collaboratively in a fast-paced environment</div></li></ul><div>
We are excited to find candidates eager to use Enterprise-AI approved tools in their work, helping us uncover opportunities for improvement and drive greater efficiencies.</div><div>
If selected for this full-time, remote role, training will begin August 17th and will last 22 weeks. The training hours are 8:00 a.m. &ndash; 4:45 p.m. EST, Monday to Friday. After training, this position will have a weekly rotating shift starting as early as 8:00 a.m. EST and working as late as 8:00 p.m. EST Monday to Friday.</div><div>
If you are passionate about delivering top-tier customer service in a fast-paced environment with opportunities for growth and development, we encourage you to apply!</div>
Job Responsibilities<ul><li>
Receiving, investigating and resolving all customer inquiries timely and accurately.</li><li>
Handling customer service inquiries and problems via the telephone.</li><li>
Ensuring all customer communication is clearly documented.</li><li>
Interact through various channels such as Chat, Phone, E-mail and TEAMS.</li><li>
Educating caller to ensure resolution is achieved on first contact.</li><li>
Must be able to pass required testing</li><li>
Participation and attendance are mandatory.</li><li>
This position requires flexibility due to rotations in schedules and requires adherence to assigned schedules</li><li>
Work overtime as required</li></ul>
Job Qualifications
Education<ul><li>
High School Diploma or equivalent</li></ul>
Experience<ul><li>
1 year - Experience in a customer service support role is required</li></ul>
Skills\Certifications<ul><li>
Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)</li><li>
Proficient oral and written communication skills</li><li>
Proficient interpersonal and organizational skills</li><li>
Exceptional time management skills</li><li>
Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment</li><li>
Independent, Sound decision-making and problem-solving skills</li><li>
If current employee with the company, must meet minimum performance expectations</li><li>
Ability to talk and type simultaneously in a clear and concise manner while interacting with customers</li></ul>
Number of Openings Available
20
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.</div>

Customer Service Trainee - Commercial

<div>The BlueCard Home Claims team is seeking a Claims Trainee who is eager to begin a career in health insurance and develop strong foundational skills in claims handling. This entry‑level role is ideal for individuals who are detail‑oriented, dependable, and interested in learning how claims move from initial receipt through resolution.
In this role, you will handle routine claims while supporting key parts of the claims process, including preliminary investigation and clear communication with internal and external partners. Your work will directly support timely and accurate claim outcomes, helping ensure our members receive the benefits they are entitled to. With training and hands‑on experience, you&rsquo;ll build confidence navigating multiple systems and applying guidelines with consistency and care.
Successful trainees are comfortable working in a fast-pace, technology‑driven environment, ask thoughtful questions, and take pride in both accuracy and productivity. No prior claims experience is required&mdash;just a High School diploma, a willingness to learn, and a commitment to delivering a reliable service. This role offers a strong starting point for growth within claims and healthcare operations.
Class Details:<ul><li>
Start Date: Monday, June 8, 2026</li><li>
Training Hours: Monday &ndash; Friday 8:00 AM &ndash; 4:30 PM (Eastern)</li><li>
Post‑Training Schedule: Monday &ndash; Friday, flexible schedule between 6:00 AM &ndash; 5:30 PM (Eastern) with additional flexibility pending system availability.</li></ul>
Job Responsibilities<ul><li>
Routing claim issues to next level or appropriate support areas; following up to ensure completion.</li><li>
Inputting, reviewing and validating the claims data received; evaluating their reliability and effectiveness in line with coverage and appraisal.</li><li>
Assisting in routine claim analysis and final determination; delivering administrative support throughout all claim handling processes.</li><li>
Performing basic investigator tasks; gathering and documenting relevant information as a preliminary investigation.</li><li>
Must be able to pass required testing.</li><li>
Work overtime as required.</li></ul>
Job Qualifications
Education<ul><li>
High School Diploma or equivalent</li></ul>
Skills\Certifications<ul><li>
Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)</li><li>
Proficient oral and written communication skills</li><li>
Proficient interpersonal and organizational skills</li><li>
Exceptional time management skills</li><li>
Independent, Sound decision-making and problem-solving skills</li><li>
If current employee with the company, must meet minimum performance expectations</li></ul>
Number of Openings Available
8
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.</div>

Claims Trainee - BlueCard Home

Join BlueCross BlueShield of Tennessee and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

BlueCross BlueShield of Tennessee

About Company

Clinical Review Manager

Customer Service Trainee - Commercial

Claims Trainee - BlueCard Home