# Clinical Criteria Escalations Specialist

**Company:** [Tennr](https://hotfix.jobs/companies/tennr)
**Location:** New York, NY
**Role:** Customer Success
**Salary:** $95k – $115k/yr
**Skills:** Utilization Management, Prior Authorization, Medical Necessity Review, Clinical Appeals, Payer Policy Review, Medical Documentation, Medicare, Medicaid, Lcds, Ncds, Hcpcs, Cpt, Icd-10, Denial Review, Dme/Hme
**Posted:** 2026-08-12

> The Clinical Criteria Escalations Specialist reviews customer feedback, payer policies, and clinical documentation to resolve medical-necessity and qualification criteria issues. The role requires an active RN or LPN license, relevant utilization-management or clinical-review experience, and strong judgment and written communication.

## Job Description

## 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.

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