Advocacy Clinical Review Coordinator I/II/III

Excellus BCBS•De Witt, AR

27d•$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 in accordance with established criteria and regulatory requirements. The role collaborates 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 researches and interprets cases; reviews medical records, contracts, and policies; prepares documentation and case responses; performs clinical reviews of quality-of-care cases and potential Medicare upholds; manages inventory; provides clinical support to colleagues; and may attend Administrative Law Judge hearings. The position also requires adherence to corporate values, conduct and privacy policies, reliable attendance, and other assigned duties. Level II adds contributions to process improvement, support for peer training and onboarding, representation of Advocacy leadership in meetings and workgroups, and preparation and presentation of reports and insights to leadership. Level III adds senior clinical review responsibilities across all lines of business, leadership of cross-functional workgroups and improvement initiatives, and strategic input to leadership on enterprise trends, risks, and regulatory considerations. The position requires a registered nurse, physician assistant, or nurse practitioner with a valid license and the specified clinical and quality/utilization review experience, or qualifying LPN appeals experience in lieu of RN. The work includes computer-based review and communication, and travel across the Health Plan service region for meetings or training may be needed. The posting notes that remote work may be possible on a case-by-case basis.

Requirements

For all levels, a 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.
For Level II, two additional years of appeals experience; alternatively, an LPN with five years of appeals experience may qualify in lieu of an RN.
For Level II, demonstrated intermediate proficiency in all related technology.
For Level III, three additional years of appeals experience; alternatively, an LPN with eight years of appeals experience may qualify 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 knowledge of 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 trainings 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 using clinical and medical expertise and established criteria.
Review medical records, contracts, and policies and provide Medical Directors with complete, accurate clinical documentation for determinations.
Document case actions 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.
Conduct 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, ensuring 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.
Attend Administrative Law Judge hearings to provide clinical support as needed.
Support the Lifetime Healthcare Companies’ mission and values, follow the Corporate Code of Conduct, and maintain member privacy in accordance with corporate policies and procedures.
Maintain regular and reliable attendance and perform other functions assigned by management.
At Level II, contribute to process improvement and help analyze and resolve complex operational issues.
At Level II, support peer-to-peer training, knowledge sharing, onboarding, and development of team members as needed.
At Level II, represent Advocacy leadership in meetings, committees, and cross-functional workgroups.
At Level II, develop, deliver, and present reports and insights to leadership, identifying trends and improvement opportunities.
At Level III, serve as a senior clinical resource with authority 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 based on enterprise trends, risk areas, and regulatory considerations.
Travel across the Health Plan service region for meetings and/or training as needed.