Advocacy Clinical Review Coordinator — Remote Options

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

Benefits offered by this job

Remote work option

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 to review medical necessity requests and expedite cases within established criteria and regulatory requirements.

The role collaborates with 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.

Responsibilities

• Research and interpret member and provider appeals, grievances, and complaints, reviewing medical records, contracts, and policies to ensure complete clinical documentation for determinations and to maintain data integrity and legal compliance.
• Prepare clear written and verbal case responses using approved templates and effectively communicate clinical decisions from Medical Directors for appropriate reading levels.
• Perform clinical reviews of quality‑of‑care cases and report findings to internal departments and the NYS DOH as required, while also conducting clinical evaluations of potential Medicare upholds prior to IRE submission.
• Evaluate and independently manage inventory and escalate concerns to Leadership to meet regulatory requirements and timelines.
• 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.

Skills

RN license or NP/PA credentials

Appeals/Utilization review experience

Clinical documentation and research

Data analysis

Multitasking and organizational skills

Education

RN/NP/PA licensure

Nurse Practitioner or Physician Assistant degree

Tools

ICD/CPT coding

DRG principles

Data analysis tools

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 to review medical necessity requests and expedite cases within established criteria and regulatory requirements.

The role collaborates with Medical Directors, Sales, Compliance, Vendors, and Legal to ensure accurate and timely decisions while managing multiple regulatory timeframes.