Clinical Appeals & Utilization Review Coordinator

Capital District Physicians Health Plan Inc; City of Rochester (NY); On-site; USD 68,000 - 125,000; Full time

Job summary

Capital District Physicians Health Plan Inc. seeks an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all lines of business.

You will review medical necessity requests and determine care appropriateness, expediting cases within regulatory timeframes. Collaborating with Medical Directors, Sales, Compliance, Vendors, and Legal, you will ensure accurate decisions and maintain data integrity while handling multiple timeframes and

Qualifications

• RN/PA/NP license required with 3 years clinical experience and 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 and policies to ensure complete documentation for determinations.
• Prepare written and verbal case responses using templates and communicate clinical decisions from Medical Directors at reading level appropriate for readers.
• Perform clinical reviews of quality-of-care cases and report findings to internal departments and NYS DOH as required.
• Evaluate and manage inventory and escalate concerns to Leadership to meet regulatory timelines.
• Act as subject matter expert to Advocacy Associates and OUCs for clinical support as needed.
• Attend hearings with Administrative Law Judges to provide clinical support as needed.

Skills

Clinical experience

Nursing license

Appeals processing

Research and data analysis

ICD/CPT coding

DRG principles

Multi-tasking

Education

Registered Nurse license (RN)

Job description

Capital District Physicians Health Plan Inc. seeks an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all lines of business.

You will review medical necessity requests and determine care appropriateness, expediting cases within regulatory timeframes. Collaborating with Medical Directors, Sales, Compliance, Vendors, and Legal, you will ensure accurate decisions and maintain data integrity while handling multiple timeframes and