Clinical Criteria Escalations Specialist
About the role
Clinical Criteria Escalations Specialist to support Qualifications team, evaluating medical necessity and documentation requirements, translating feedback into actionable guidance for criteria writers and customer-facing teams.
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.
Qualifications
- 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.
- Familiarity with LCDs, NCDs, HCPCS, CPT, ICD-10, denial review, or criteria-heavy workflows like DME/HME, infusion, or specialty pharmacy is a plus.
Skills
Benefits
- Beautiful new office at 345 Hudson Street
- Unlimited PTO
- 100% paid employee health benefit options
- Employer-funded 401(k) match
- Competitive parental leave
- Free lunch! Plus a pantry full of snacks.
About Tennr
Fast, Transparent Patient Experiences
Tennr is solving the black hole problem in healthcare by leveraging models to digitize the flow of paperwork between healthcare providers. -- Today, when you go to your doctor and need to be referred to a specialist (e.g., for sleep apnea), your doctor sends a fax (yes, in 2024, 90% of provider-provider communication is a 1980s fax). These are often converted into 20+ page PDFs, with handwritten (doctor’s handwriting!) notes, in thousands of different formats. The problem is so complex that a person has to read it, type it up, and manually enter your information. Tennr built RaeLM™ (7B—trained on 3M+ documents) to read these docs, talk to your doc to ensure nothing is missed, and text you to help schedule your appointment so you can get better, faster.
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