Clinical Coordinator

• 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

Explore Advocacy Clinical Review Coordinator I/II/III at LTHC. Review requirements and application details.