Job Responsibilities
- Initiate referrals and support care coordination workflows by gathering required clinical information and confirming benefit completeness under established UM procedures.
- Perform structured clinical reviews (e.g., precertification support, retrospective claim review preparation, and appeal packet preparation) using preset criteria and templates, escalating any findings that require RN/Medical Director interpretation.
- Consult with supervising RN or Medical Director when requests involve clinical questions, exceptions, or scenarios requiring higher level clinical judgment, consistent with the LPN’s directed scope of practice.
- Assist nonclinical staff by clarifying clinical documentation, interpreting request elements within LPN practice parameters, and ensuring accurate case setup for RN/MD decision-making.
- Apply approved medical appropriateness criteria and contractual eligibility information solely to support intake validation and preparation of clinical review materials, without independently determining medical necessity, denying, reducing, terminating services, or issuing adverse determinations.
- Document all review activities in required UM systems with accuracy, completeness, and adherence to regulatory (NCQA/URAC/CMS) documentation standards.
- Communicate with providers, members, and internal teams regarding missing documentation, process requirements, and case status, using approved scripts and escalation pathways.
- Participate in quality improvement, compliance activities, and competency requirements tied to UM program standards.
Job Qualifications
License
- Licensed Practical Nurse (LPN) 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
- 1-2 years - Clinical experience required
SkillsCertifications
- Knowledge of community resources, benefits, and service authorization processes.
- Familiarity with care management frameworks and regulatory requirements.
- High attention to detail with the ability to document accurately and meet regulatory standards (NCQA, URAC, CMS).
This job description is not intended to expand the scope of practice of a Licensed Practical Nurse beyond applicable state licensure laws or to confer independent clinical authority reserved to Registered Nurses or physicians.
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.