Advocacy Clinical Appeals Coordinator

Excellus BCBS; United States; Hybrid; USD 62,000 - 129,000; Full time

Job summary

Excellus BCBS seeks an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all lines of business. Using clinical nursing and medical expertise, you will review medical necessity requests, determine appropriateness of care, and expedite cases within regulatory timelines.

You will collaborate with Medical Directors, Sales, Compliance, Vendors, and Legal to ensure accurate, timely decisions while maintaining data integrity and member

Qualifications

• RN/PA/NP licensed with at least 3 years clinical experience and 1 year in quality/utilization review.
• Experience in research, data analysis, ICD/CPT coding; appeals processing preferred.
• Ability to multitask and prioritize; basic computer skills; navigate several systems.
• Demonstrates integrity and privacy compliance per corporate policies.

Responsibilities

• Research and interpret member/provider appeals, grievances and complaints; ensure complete documentation.
• Prepare clear written/verbal case responses using templates and communicate clinical decisions.
• Conduct clinical reviews of quality-of-care cases and report findings to required parties.
• Collaborate with Medical Directors, Sales, Compliance, Vendors and Legal for timely decisions.
• Escalate regulatory timelines to Leadership and support hearings when needed.
• Act as clinical SME to Advocacy Associates and OUCs as necessary.

Skills

Clinical nursing

Quality/utilization review

Research & data analysis

ICD/CPT coding

Documentation & data integrity

Regulatory awareness

Education

Registered Nurse license

Physician Assistant license

Nurse Practitioner license

LPN with appeals experience

Tools

EHR systems

Multiple systems navigation

Job description

Excellus BCBS seeks an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all lines of business. Using clinical nursing and medical expertise, you will review medical necessity requests, determine appropriateness of care, and expedite cases within regulatory timelines.

You will collaborate with Medical Directors, Sales, Compliance, Vendors, and Legal to ensure accurate, timely decisions while maintaining data integrity and member