Clinical Criteria Escalations Specialist

Tennr•New York, NY

2d•$95,000 - $115,000•Hybrid

About The Position

We're seeking a Clinical Criteria Escalations Specialist to support our Qualifications team, the product customers rely on to evaluate medical necessity and documentation requirements. In this role, you'll own customer feedback, custom criteria requests, and clinical escalations, determining whether feedback represents a true criteria issue, a payer policy interpretation question, a documentation gap, or a customer-specific preference, and turning it into clear, actionable guidance. This is a great fit for an RN or LPN with experience in utilization management, prior authorization, clinical appeals, CDI, medical necessity review, or payer policy review. You should be comfortable reading payer policies, reviewing clinical documentation, and making sense of ambiguous feedback with strong clinical judgment.

Requirements

Active RN or LPN license.
Experience in utilization management, prior authorization, medical necessity review, clinical appeals, payment integrity, CDI, payer policy review, or DME/HME qualification review.
Strong understanding of medical necessity, payer policy, and clinical documentation, with the ability to distinguish policy-backed requirements from customer preference or workflow variation.
Strong written communication, attention to detail, and judgment around when to resolve, document, or escalate.

Nice To Haves

Familiarity with LCDs, NCDs, HCPCS, CPT, ICD-10, denial review, or criteria-heavy workflows like DME/HME, infusion, or specialty pharmacy is a plus.

Responsibilities

Review and triage customer feedback related to qualification criteria, medical necessity logic, documentation requirements, and payer policy interpretation.
Review custom criteria requests and translate clinical requirements into clear internal guidance for criteria writers, reviewers, and customer-facing teams.
Read and interpret payer policies, Medicare/Medicaid guidance, and customer-provided documentation, validating that criteria align with the correct payer, code, policy source, and clinical scenario.
Partner with internal teams to resolve criteria-related escalations and close the loop on customer feedback.
Identify recurring feedback themes and help improve internal criteria standards, review guidance, and escalation processes.