Advocacy Clinical Review Coordinator I/II/III

Univera Healthcare•Albany, NY

24d

About The Position

The Advocacy Clinical Review Coordinator investigates member and provider appeals, grievances, and complaints across all lines of business. The role applies clinical nursing and medical expertise to review medical necessity requests, assess appropriateness of care, and expedite cases according to established criteria and regulatory requirements. It collaborates with internal and external partners, including Medical Directors, Sales, Compliance, vendors, and Legal, to support accurate, timely decisions while managing multiple regulatory timeframes. At Level I, the coordinator researches appeals, grievances, and complaints; reviews medical records, contracts, and policies; and provides Medical Directors with complete clinical documentation. The role documents actions, prepares case responses, communicates Medical Director decisions, performs quality-of-care reviews, evaluates potential Medicare upholds before IRE submission, manages case inventory, and escalates concerns. It also provides clinical support to Advocacy Associates and OUCs and may attend Administrative Law Judge hearings. Level II adds contributions to process improvements and complex operational issue resolution, peer training and knowledge sharing, representation of Advocacy leadership in meetings and workgroups, and development and presentation of reports and insights to leadership. Level III adds senior clinical review authority across all lines of business, leadership of cross-functional workgroups and improvement initiatives, ownership of recommendations and outcomes for complex operational issues, and strategic input to leadership on enterprise trends, risks, and regulatory considerations. The position requires maintaining member privacy, adhering to the Corporate Code of Conduct and Lifetime Healthcare Companies’ mission and values, and regular and reliable attendance. Other functions may be assigned by management. The role may involve travel across the Health Plan service region for meetings or training. Remote work may be possible on a case-by-case basis.

Requirements

Registered Nurse, Physician Assistant, or Nurse Practitioner with a valid license, and at least three years of clinical experience and one year in quality/utilization review; alternatively, an LPN with three years of appeals experience may qualify in lieu of an RN.
Experience in research, data analysis, ICD/CPT coding, and DRG principles; appeals processing experience preferred.
Basic computer skills and ability to navigate multiple systems simultaneously.
Intermediate organizational and problem-solving skills, with ability to multitask and prioritize.
For Level II, two additional years of appeals experience beyond Level I requirements, or an LPN with five years of appeals experience accepted in lieu of an RN.
For Level II, demonstrated intermediate proficiency in related technology.
For Level III, three additional years of appeals experience beyond Level II requirements, or an LPN with eight years of appeals experience accepted in lieu of an RN.
For Level III, advanced ability to apply clinical and medical expertise across multiple lines of business.
For Level III, expert Utilization Management knowledge and ability to independently handle complex assignments and high-profile business cases.
Ability to hear, understand, and speak clearly while using a phone, with or without a headset.
Ability to work sitting and/or standing at a workstation while viewing a computer and using a keyboard, mouse, and/or phone for three or more hours at a time.
Ability to travel across the Health Plan service region for meetings and/or training as needed.

Nice To Haves

Appeals processing experience.

Responsibilities

Investigate member and provider appeals, grievances, and complaints across all lines of business.
Review medical necessity requests and determine appropriateness of care using clinical and medical expertise.
Research and interpret cases; review medical records, contracts, and policies to provide Medical Directors with complete and accurate clinical documentation.
Document actions thoroughly to maintain data integrity and legal compliance.
Prepare clear written and verbal case responses using approved templates and communicate Medical Director decisions at appropriate reading levels.
Perform clinical reviews of quality-of-care cases and report findings to internal departments and the NYS DOH as required.
Conduct clinical evaluations of potential Medicare upholds before IRE submission to ensure findings are accurate and supported.
Manage case inventory independently and escalate concerns to leadership to help meet regulatory requirements and timelines.
Provide clinical support as a subject matter expert to Advocacy Associates and OUCs, and attend Administrative Law Judge hearings as needed.
For Level II, contribute to process-improvement initiatives and help analyze and resolve complex operational issues.
For Level II, support peer-to-peer training and knowledge sharing, including onboarding and development of team members as needed.
For Level II, represent Advocacy leadership in meetings, committees, and cross-functional workgroups.
For Level II, develop and present reports and insights to leadership, identifying trends and improvement opportunities.
For Level III, serve as a senior clinical resource authorized to review cases across all lines of business.
For Level III, lead cross-functional workgroups and process-improvement initiatives and own outcomes and recommendations for complex operational issues.
For Level III, provide leadership with strategic input on enterprise trends, risk areas, and regulatory considerations.
Protect member privacy, adhere to corporate policies and the Code of Conduct, and support the company’s mission and values.
Maintain regular and reliable attendance and perform other functions assigned by management.