Advocacy Clinical Review Coordinator I/II/III

Job Description: Summary: 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. Essential Accountabilities: Level I 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 qualityofcare 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. Level II (in addition to Level I) 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 crossfunctional workgroups, ensuring consistent communication and alignment. 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 crossfunctional workgroups and process improvement initiatives, owning outcomes and recommendations for complex operational issues. Provides strategic input to leadership based on enterpriselevel trends, risk areas, and regulatory considerations. Minimum Qualifications All Levels 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. Level II (in addition to level I) 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. Level III (in addition to level II) 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. Physical 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. 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 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. Please note: There may be opportunity for remote work within all jobs posted by the CDPHP 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. #J-18808-Ljbffr Capital District Physicians Health Plan Inc