Clinical Criteria Escalations Specialist

Tennr
New York
Workplace: HybridFull timeUSD 95,000 - 115,000 annuallyFunction: Healthcare (Clinical, Medical, Wellness)Skills: ["Clinical judgment","Written communication","Attention to detail","Customer feedback triage","Problem-solving"]

Own clinical criteria escalations for the Qualifications team by triaging customer feedback, validating payer policies, and interpreting documentation to determine whether issues reflect true criteria gaps, payer interpretations, documentation gaps, or preferences. Translate custom criteria requests into actionable guidance for internal teams and customer-facing groups. Identify recurring themes to improve internal standards and escalation processes across utilization management and medical necessity workflows.

Loading

Loading job details...

Preparing the role view and application actions.

FursaFursa
Tennr
Tennr
1 day ago

Clinical Criteria Escalations Specialist

✓ Verified Job

Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 6 hours agoStatus: Live

Job Summary

Own clinical criteria escalations for the Qualifications team by triaging customer feedback, validating payer policies, and interpreting documentation to determine whether issues reflect true criteria gaps, payer interpretations, documentation gaps, or preferences. Translate custom criteria requests into actionable guidance for internal teams and customer-facing groups. Identify recurring themes to improve internal standards and escalation processes across utilization management and medical necessity workflows.
Location: New York
Workplace: Hybrid
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)

Key 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 to validate criteria alignment to 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 to improve internal criteria standards, review guidance, and escalation processes.

Pay and Benefits

Salary: USD 95,000 - 115,000 annually
Schedule:4-Day Week
Perks:Paid LeaveHealth Insurance401k MatchParental Leave

Key Requirements

  • •Active RN or LPN license.
  • •Experience in utilization management, prior authorization, medical necessity review, clinical appeals, CDI, payment integrity, 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.
  • •Ability to read and interpret payer policies and customer-provided documentation to validate criteria alignment with the correct payer, code, policy source, and clinical scenario.
  • •Familiarity with LCDs, NCDs, HCPCS, CPT, ICD-10, denial review, or criteria-heavy workflows like DME/HME, infusion, or specialty pharmacy is a plus.
Experience:HealthcareUtilization managementPrior authorizationMedical necessityPayer policyClinical appealsCDIPayment integrityDME/HME
Skills:Clinical judgmentWritten communicationAttention to detailCustomer feedback triageProblem-solving
Licenses:RNLPN

Company Brief

Tennr
Tennr is a tennis-focused platform that helps players find opponents, book courts, discover coaching, and join local tennis events. It aims to simplify match-making and court access for recreational and competitive tennis enthusiasts.
Industry: Online Marketplaces
Website