Advocacy Clinical Review Coordinator I/II/III

Excellus BCBS • Albany, NY

25d

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 works with internal and external partners, including Medical Directors, Sales, Compliance, Vendors, and Legal, to support accurate, timely decisions and manage multiple regulatory timeframes.

At Level I, the coordinator reviews records, contracts, and policies; prepares complete clinical documentation for Medical Directors; documents actions; communicates decisions; reviews quality-of-care cases and potential Medicare upholds; manages case inventory and escalates concerns; and provides clinical support to colleagues and at hearings as needed. Level II adds process-improvement work, peer training, cross-functional representation, and reporting to leadership. Level III serves as a senior clinical resource, leads cross-functional workgroups and improvement initiatives, and provides strategic input to leadership.

The role requires a valid license as an RN, Physician Assistant, or Nurse Practitioner, or qualifying LPN appeals experience in lieu of RN. Physical requirements include phone communication, extended workstation use, and travel across the Health Plan service region for meetings or training as needed. Remote work may be possible on a case-by-case basis.

Requirements

• Valid license as a Registered Nurse, Physician Assistant, or Nurse Practitioner, with 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.
• Basic computer skills and ability to navigate multiple systems simultaneously.
• Intermediate organizational and problem-solving skills, with ability to multitask and prioritize.
• Level II: Two additional years of appeals experience; alternatively, an LPN with five years of appeals experience may qualify in lieu of an RN.
• Level II: Demonstrated intermediate proficiency in all related technology.
• Level III: Three additional years of appeals experience beyond Level II; alternatively, an LPN with eight years of appeals experience may qualify in lieu of an RN.
• Level III: Advanced ability to apply clinical and medical expertise across multiple lines of business.
• Level III: Expertise in Utilization Management 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 is preferred.

Responsibilities

• Investigate member and provider appeals, grievances, and complaints across all lines of business.
• Review medical necessity requests and determine appropriateness of care within established criteria and regulatory requirements.
• Review medical records, contracts, and policies and ensure Medical Directors receive complete, accurate clinical documentation for determinations.
• Document actions thoroughly to maintain data integrity and legal compliance.
• Prepare 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 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 hearings with Administrative Law Judges to provide clinical support as needed.
• At Level II, contribute to process-improvement initiatives and help analyze and resolve complex operational issues.
• At Level II, support peer-to-peer training and knowledge sharing, including onboarding and development of team members.
• At Level II, represent Advocacy leadership in meetings, committees, and cross-functional workgroups.
• At Level II, develop and present reports and insights to leadership, identifying trends and improvement opportunities.
• At Level III, serve as a senior clinical resource authorized to review appeals, grievances, and complaints across all lines of business.
• At Level III, lead cross-functional workgroups and process-improvement initiatives and own outcomes and recommendations for complex operational issues.
• At Level III, provide leadership with strategic input on enterprise trends, risk areas, and regulatory considerations.
• Support the Lifetime Healthcare Companies’ mission and values, follow the Corporate Code of Conduct, and uphold Lifetime Way values and beliefs.
• Maintain member privacy in accordance with corporate privacy policies and procedures.
• Maintain regular and reliable attendance and perform other functions assigned by management.

Benefits

• Group health and/or dental insurance may be included in the total rewards package.
• Retirement plan may be included in the total rewards package.
• Wellness program may be included in the total rewards package.
• Paid time away from work may be included in the total rewards package.
• Paid holidays may be included in the total rewards package.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed