Senior Clinical Appeals Coordinator

Excellus BCBS; Town of De Witt (NY); On-site; USD 90,000 - 130,000; Full time

Job summary

Excellus BCBS seeks an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints. You will use clinical nursing and medical expertise to review medical necessity requests and determine care appropriateness while expediting cases to meet regulatory timeframes.

You will collaborate with Medical Directors, Sales, Compliance, Vendors, and Legal to ensure accurate decisions and maintain data integrity across systems.

Qualifications

• RN/PA/NP licensed with 3+ years clinical experience and 1 year in quality/utilization review; or LPN with appeals experience.
• Experience in research, data analysis, ICD/CPT coding; appeals processing preferred.
• Basic computer skills and ability to navigate multiple systems.

Responsibilities

• Research and interpret member and provider appeals, grievances and complaints across lines of business.
• Prepare clear written and verbal case responses using templates and communicate clinical decisions.
• Perform clinical reviews of quality-of-care cases and report findings to required parties.
• Evaluate inventory and escalate regulatory timing concerns to leadership.
• Provide clinical support to Advocacy Associates and attend hearings as needed.

Skills

Clinical knowledge

Data analysis

Communication skills

Multi-tasking

Problem solving

Education

RN/PA/NP license

LPN with appeals experience

Quality/utilization review experience

Tools

ICD/CPT coding

DRG principles

Job description

Excellus BCBS seeks an Advocacy Clinical Review Coordinator to investigate member and provider appeals, grievances, and complaints. You will use clinical nursing and medical expertise to review medical necessity requests and determine care appropriateness while expediting cases to meet regulatory timeframes.

You will collaborate with Medical Directors, Sales, Compliance, Vendors, and Legal to ensure accurate decisions and maintain data integrity across systems.