Advocacy Clinical Review Coordinator I/II/III

. Investigate member and provider appeals, grievances, and complaints across all lines of business .

Posted 10/15/2026full-timeAlbany • New York • United StatesMid-LevelSenior💰 $62,400 - $129,384 per yearWebsite

Key responsibilities & impact

Investigate member and provider appeals, grievances, and complaints across all lines of business
Review medical necessity requests and determine appropriateness of care
Expedite cases within established criteria and regulatory requirements
Research and interpret appeals, grievances, and complaints using clinical and medical expertise
Review medical records, contracts, and policies and provide complete clinical documentation for Medical Director determinations
Document actions to maintain data integrity and legal compliance
Prepare written and verbal case responses using approved templates
Communicate clinical decisions from Medical Directors at appropriate reading levels
Perform clinical reviews of quality-of-care cases and report findings to internal departments and the NYS DOH
Conduct clinical evaluations of potential Medicare upholds before IRE submission
Manage inventory and escalate concerns to leadership to meet regulatory requirements and timelines
Provide clinical support to Advocacy Associates and OUCs
Attend hearings with Administrative Law Judges as needed
Level II: Contribute to process improvement, complex operational issue resolution, peer training, meetings, committees, workgroups, and leadership reporting
Level III: Serve as a senior clinical resource, lead cross-functional workgroups and process improvements, and provide strategic input to leadership

What you’ll need

Registered Nurse, Physician Assistant, or Nurse Practitioner with valid license required; or LPN with 3 years of appeals experience accepted in lieu of RN
Minimum of 3 years clinical experience and 1 year in quality/utilization review
Experience in research, data analysis, ICD/CPT coding, DRG principles; appeals processing preferred
Basic computer skills and ability to navigate multiple systems simultaneously
Intermediate organizational and problem-solving skills; ability to multitask and prioritize
Level II: 2 additional years of appeals experience, or LPN with 5 years of appeals experience accepted in lieu of RN
Level II: Intermediate proficiency in all related technology
Level III: 3 additional years of appeals experience, or LPN with 8 years of appeals experience accepted in lieu of RN
Level III: Advanced ability to apply clinical and medical expertise across multiple lines of business
Level III: Expertise in Utilization Management and ability to independently handle complex assignments and high-profile business cases
Ability to hear, understand, and speak clearly while using a phone
Ability to work at a computer workstation using keyboard, mouse, and/or phone for 3 or more hours at a time
Ability to travel across the Health Plan service region for meetings and/or trainings as needed

Comp & perks