Remote Senior Clinical Appeals Coordinator

Univera HealthСare; City of Albany (NY); Hybrid; USD 62,000 - 129,000; Full time

Job summary

Univera Healthcare is seeking an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all business lines. You will review medical necessity requests, determine appropriateness of care, and expedite cases within regulatory timelines.

The role collaborates with Medical Directors, Sales, Compliance, and Legal to ensure accurate decisions, while maintaining data integrity, privacy, and timely communications with stakeholders.

Qualifications

• Licensed nurse or advanced practice license with 3+ years clinical experience and 1 year in quality/utilization review.
• Experience in appeals processing is preferred.
• Ability to navigate multiple systems simultaneously.
• Demonstrates analytical and problem-solving skills.

Responsibilities

• Research and interpret member/provider appeals, reviewing medical records and policies.
• Prepare written/verbal case responses using approved templates.
• Perform clinical reviews and report findings to NYS DOH as required.
• Evaluate and manage documentation to maintain regulatory compliance.
• Lead and support cross-functional teams on process improvements.

Skills

Clinical nursing

Data analysis

ICD/CPT coding

Regulatory knowledge

Documentation

Communication

Multi-tasking

Education

RN/PA/NP license

LPN license with 3+ appeals experience

Job description

Univera Healthcare is seeking an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints across all business lines. You will review medical necessity requests, determine appropriateness of care, and expedite cases within regulatory timelines.

The role collaborates with Medical Directors, Sales, Compliance, and Legal to ensure accurate decisions, while maintaining data integrity, privacy, and timely communications with stakeholders.