Advocacy Clinical Review Coordinator I/II/III

company•City of Utica, NY

18d•$62,400 - $129,384

About The Position

The Advocacy Clinical Review Coordinator investigates member and provider appeals, grievances, and complaints across all lines of business. Using clinical nursing and medical expertise, the coordinator reviews medical necessity requests, determines appropriateness of care, and expedites cases according to established criteria and regulatory requirements. The role collaborates with internal and external partners, including Medical Directors, Sales, Compliance, Vendors, and Legal, to ensure accurate and timely decisions while managing multiple regulatory timeframes. At Level I, the coordinator researches and interprets appeals, grievances, and complaints; reviews medical records, contracts, and policies; prepares case responses and communicates Medical Director decisions; conducts quality-of-care reviews and clinical evaluations of potential Medicare upholds; manages inventory and escalates concerns; and provides clinical support to colleagues and at hearings as needed. The position also requires accurate documentation, protection of member privacy, adherence to corporate values and conduct standards, and regular, reliable attendance. Level II adds contributions to process improvement and complex operational problem-solving, peer training and knowledge sharing, representation of Advocacy leadership in meetings and workgroups, and the preparation 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 issues, and strategic input to leadership on enterprise trends, risks, and regulatory matters. The position requires the ability to hear, understand, and speak clearly by phone; work at a workstation using a computer and related equipment for extended periods; and travel across the Health Plan service region for meetings or training as needed. Remote work may be available on a case-by-case basis. Compensation ranges are $62,400–$106,929 for Level I, $65,346–$117,622 for Level II, and $71,880–$129,384 for Level III. Total rewards may also include group health and/or dental insurance, a retirement plan, a wellness program, paid time away from work, and paid holidays.

Requirements

For all levels, be a 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 is accepted in lieu of an RN.
Experience in research, data analysis, ICD/CPT coding, and DRG principles.
Basic computer skills and ability to navigate multiple systems simultaneously.
Intermediate organizational and problem-solving skills, with the ability to multitask and prioritize.
For Level II, have two additional years of appeals experience; alternatively, an LPN with five years of appeals experience is accepted in lieu of an RN.
For Level II, demonstrate intermediate proficiency in all related technology.
For Level III, have three additional years of appeals experience; alternatively, an LPN with eight years of appeals experience is accepted in lieu of an RN.
For Level III, demonstrate advanced ability to apply clinical and medical expertise across multiple lines of business.
For Level III, be an expert in Utilization Management and 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 is preferred.

Responsibilities

Research and interpret member and provider appeals, grievances, and complaints using clinical and medical expertise.
Review medical records, contracts, and policies to provide Medical Directors with complete and accurate clinical documentation for determinations.
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.
Conduct clinical reviews of quality-of-care cases and report findings to internal departments and the NYS DOH as required.
Evaluate potential Medicare upholds before IRE submission, ensuring clinical findings are accurate and supported.
Manage case inventory independently and proactively escalate concerns to Leadership to meet regulatory requirements and timelines.
Provide clinical support as a subject matter expert to Advocacy Associates and OUCs as needed.
Attend Administrative Law Judge hearings to provide clinical support as needed.
Maintain member privacy and adhere to corporate privacy policies, procedures, conduct standards, mission, and values.
Contribute to process improvement initiatives and help analyze and resolve complex operational issues and activities (Level II and III).
Support peer-to-peer training and knowledge sharing, including onboarding and development of team members (Level II and III).
Represent Advocacy leadership in internal and external meetings, committees, and cross-functional workgroups (Level II and III).
Develop, deliver, and present reports and insights to leadership, identifying trends and improvement opportunities (Level II and III).
Serve as a senior clinical resource authorized to review appeals, grievances, and complaints across all lines of business (Level III).
Lead cross-functional workgroups and process improvement initiatives, owning outcomes and recommendations for complex operational issues (Level III).
Provide leadership with strategic input based on enterprise-level trends, risk areas, and regulatory considerations (Level III).
Perform other functions as assigned by management.
Maintain regular and reliable attendance.
Travel across the Health Plan service region for meetings and/or training as needed.