Advocacy Clinical Review Coordinator I/II/III

Responsibilities

Leverages clinical and medical expertise to research and interpret member and provider appeals, grievances, and complaints, while reviewing medical records, contracts, and policies to ensure Medical Directors receive complete and accurate clinical documentation for determinations and thoroughly documenting all actions to maintain data integrity and legal compliance

Prepares clear written and verbal case responses using approved templates & effectively communicates clinical decisions from Medical Directors for appropriate reading levels

Performs clinical reviews of quality‑of‑care cases and reports findings to internal departments and the NYS DOH as required, while also conducting clinical evaluations of potential Medicare upholds prior to IRE submission to ensure all clinical findings are accurate and fully supported

Evaluates and independently manages inventory and proactively escalates any concerns to Leadership to ensure regulatory requirements and timelines measures are met

Act as subject matter expert to Advocacy Associates and OUCs to provide clinical support as necessary

Attend hearings with Administrative Law Judges to provide clinical support as needed

Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs

Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures

Regular and reliable attendance is expected and required

Performs other functions as assigned by management

Contributes to process improvement initiatives, assisting with the analysis and resolution of more complex operational issues and activities

Supports peer-to-peer training and knowledge sharing, helping to onboard and develop team members as needed

Represents Advocacy leadership in internal and external meetings, committees, and cross‑functional workgroups, ensuring consistent communication and alignment

Develops, delivers, and presents reports and insights to leadership, identifying trends and opportunities for improvement

Serves as a senior clinical resource with authority to review appeals, grievances, and complaints across all lines of business

Leads and drives cross‑functional workgroups and process improvement initiatives, owning outcomes and recommendations for complex operational issues

Provides strategic input to leadership based on enterprise‑level trends, risk areas, and regulatory considerations

Preferred

Experience in research, data analysis, ICD/CPT coding, DRG principles

appeals processing preferred

Benefits

May include participation in group health and/or dental insurance

May include participation in a retirement plan

May include participation in a wellness program

May include paid time away from work

May include paid holidays

There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team; this decision is made on a case-by-case basis.

Glassdoor

3.4

Health insurance plans and coverage provider.

Rochester, New York, USA

https://www.excellusbcbs.com/

Late Stage

Leadership Team

Jeremy Donath

Director, Provider Reimbursement Analytics & Operations

Recent News

Rochester Business Journal

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TechTarget

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Qualifications

Registered Nurse, Physician Assistant, or Nurse Practitioner with valid license required with a minimum of three (3) years clinical experience and one (1) year in quality/utilization review; or an LPN with 3 years of appeals experience accepted in lieu of RN

Basic computer skills; ability to navigate multiple systems simultaneously

Demonstrates intermediate, organizational, and problem-solving skills; ability to multi-task and prioritize

Two (2) additional years of appeals experience; or an LPN with five (5) years of appeals experience accepted in lieu of RN

Demonstrated intermediate proficiency in all related technology

Three (3) additional years of appeals experience; or an LPN with eight (8) years of appeals experience accepted in lieu of RN

Advanced ability to apply clinical and medical expertise across multiple lines of business

Expert in Utilization Management & ability to handle complex assignments & high-profile business cases independently

Experience in research, data analysis, ICD/CPT coding, DRG principles

Appeals processing preferred

Registered Nurse, Physician Assistant, or Nurse Practitioner with valid license required with a minimum of three (3) years clinical experience and one (1) year in quality/utilization review; or an LPN with 3 years of appeals experience accepted in lieu of RN.

Two (2) additional years of appeals experience; or an LPN with five (5) years of appeals experience accepted in lieu of RN.

Three (3) additional years of appeals experience; or an LPN with eight (8) years of appeals experience accepted in lieu of RN.

Required skills

Clinical Review, Quality/Utilization Review, Appeals Processing, Medical Necessity Review, ICD/CPT Coding, DRG Principles, Data Analysis, Utilization Management, Clinical Documentation

Preferred skills

appeals processing preferred

Experience

3-8 years