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Clinical Criteria Escalations Specialist

🕒 23 days ago
Clinical JudgmentUtilization ManagementPrior AuthorizationMedical Necessity Review

📜 Description

  • 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.
  • 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 and escalation processes.

🛠️ 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.
  • 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 is a plus.

Benefits

  • Unlimited PTO
  • 100% paid employee health benefit options
  • Competitive parental leave
  • Review and triage customer feedback related to qualification criteria, medical necessity logic, documentation requirements, and payer policy interpretation.
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