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.

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.

Requirements

• Level I:
  • Leverages clinical and medical expertise to research and interpret member and provider appeals, grievances, and complaints.
  • Prepares clear written and verbal case responses using approved templates.
  • Performs clinical reviews of quality‑of‑care cases and reports findings to internal departments and the NYS DOH.
  • Evaluates and independently manages inventory and proactively escalates any concerns to Leadership.
  • 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.
  • 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.
• Level II (in addition to Level I):
  • Contributes to process improvement initiatives, assisting with the analysis and resolution of more complex operational issues.
  • 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.
  • Develops, delivers, and presents reports and insights to leadership, identifying trends and opportunities for improvement.
• Level III (in addition to Level II):
  • 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.
  • Provides strategic input to leadership based on enterprise‑level trends, risk areas, and regulatory considerations.

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
• Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education.
• Participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
• Opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team, made on a case-by-case basis.