Clinical Criteria Escalations Specialist, RN/LPN in Healthcare Payer Policy
Overview
The role owns clinical escalation workflows for medical necessity criteria and payer policy interpretation at Tennr. You will translate complex feedback into actionable guidance for criteria writers and customer teams, ensuring alignment with payer policies and clinical documentation. This position suits an RN or LPN with utilization management experience and strong clinical judgment. You’ll join a collaborative team focused on reducing patient delays in the U.S. healthcare system and contribute to improving criteria standards and escalation processes.
What You'll Do5
- 1Review and triage customer feedback related to qualification criteria and payer policy interpretation
- 2Translate clinical requirements into internal guidance for criteria writers and reviewers
- 3Read and interpret payer policies and documentation to validate alignment with correct payer and policy source
- 4Partner with internal teams to resolve escalations and close the feedback loop
- 5Identify recurring feedback themes and help improve internal criteria standards and escalation processes
Requirements5
- 1Active RN or LPN license
- 2Experience in utilization management, prior authorization, medical necessity review, or clinical appeals
- 3Strong understanding of medical necessity and payer policy with ability to distinguish policy requirements from customer preference
- 4Strong written communication and attention to detail
- 5Familiarity with LCDs, NCDs, HCPCS, CPT, ICD-10 or DME/HME workflows is a plus
Salary Insight
$10 - $115k per year
Location
Required Skills
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