Clinical Criteria Escalations Specialist

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.

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.
• 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 such as DME/HME, infusion, or specialty pharmacy.

Compensation and Benefits

• Annual salary: $95,000–$115,000.
• Unlimited PTO.
• 100% paid employee health benefit options.
• Employer-funded 401(k) match.
• Competitive parental leave.
• Free lunch and an office pantry stocked with snacks.