[Hiring] Advocacy Clinical Review Coordinator I/II/III @company

Role Description

The Advocacy Clinical Review Coordinator investigates member and provider appeals, grievances, and complaints across all lines of business. Using clinical nursing and medical expertise, they will review medical necessity requests, determine appropriateness of care, and expedite cases within established criteria and regulatory requirements. The position 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.

• Leverages clinical and medical expertise to research and interpret member and provider appeals, grievances, and complaints.
• Reviews medical records, contracts, and policies to ensure Medical Directors receive complete and accurate clinical documentation for determinations.
• Thoroughly documents 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.
• Conducts 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.
• Acts as subject matter expert to Advocacy Associates and OUCs to provide clinical support as necessary.
• Attends 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.
• 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.

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.
• Experience in research, data analysis, ICD/CPT coding, DRG principles; appeals processing preferred.
• 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.

Requirements

• Ability to hear, understand, and speak clearly while using a phone, with or without a headset.
• Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.

Benefits

• Compensation Range(s):
• Level I: Grade E3: Minimum: $62,400 - Maximum: $106,929
• Level II: Grade E4: Minimum: $65,346 - Maximum: $117,622
• Level III: Grade E5: Minimum: $71,880 - Maximum: $129,384
• The salary range indicated in this posting represents the minimum and maximum of the salary range for this position.
• Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity.
• The posted salary range reflects just one component of our total rewards package.
• Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Company Description

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Please note: 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.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.