Clinical Criteria Escalations Specialist

2 нед. назад

95k–115k USD / yearUSAHybrid

clinical documentation review

Support Qualifications team by managing clinical escalations and customer feedback related to medical necessity and documentation requirements.

Обязанности

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.

Требования

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.

Условия

Beautiful new office at 345 Hudson Street
Unlimited PTO
100% paid employee health benefit options
Employer-funded 401(k) match
Competitive parental leave

Другое

Today, when you go to your doctor and get referred to a specialist, your doctor sends out a referral and tells you, "They'll be in touch soon." So you wait. And wait. Sometimes days, weeks, or even months. Why? Because too often providers are overwhelmed with the painstakingly tedious work required to get paid by insurance companies. Powered by proprietary models, handles the complex paperwork that gets patients through the door and providers paid, helping operators get patients the right care, at the right time, in the right setting.
We're seeking a Clinical Criteria Escalations Specialist to support our Qualifications team, the product customers rely on to evaluate medical necessity and documentation requirements. In this role, you'll own customer feedback, custom criteria requests, and clinical escalations, determining whether feedback represents a true criteria issue, a payer policy interpretation question, a documentation gap, or a customer-specific preference, and turning it into clear, actionable guidance.
This is a great fit for an RN or LPN with experience in utilization management, prior authorization, clinical appeals, CDI, medical necessity review, or payer policy review. You should be comfortable reading payer policies, reviewing clinical documentation, and making sense of ambiguous feedback with strong clinical judgment.
Drive Impact: one of our company values is Cowboy, meaning you set the pace. You won't just talk about things, you'll get them done. And feel the impact.
Develop Operational Expertise: learn the inner workings of scaling systems, tools, and infrastructure
Innovate with Purpose: we're not just doing this for fun (although we do have a lot of fun). At , you'll join a high-caliber team maniacally focused on reducing patient delays across the U.S. healthcare system.
Build Relationships: collaborate and connect with like-minded, driven individuals in our Hudson Square office 4 days/week
Free lunch! Plus a pantry full of snacks.