Clinical Criteria Escalations Specialist

About the role

The Clinical Criteria Escalations Specialist owns the end-to-end lifecycle of customer feedback and clinical escalations within the Qualifications product area. This role is responsible for transforming ambiguous provider input into precise, actionable guidance that clarifies medical necessity and documentation expectations. You will act as the critical bridge between customer concerns and internal criteria writers, ensuring that responses are accurate, policy-aligned, and operationally sound. The position requires strong clinical judgment to differentiate between true criteria gaps, payer policy nuances, and documentation deficiencies. You will directly influence how quickly and correctly patients gain access to necessary care. This is an ideal role for an RN or LPN who thrives in complex, detail-oriented healthcare environments. Your work will have a direct impact on reducing patient delays and improving the accuracy of qualification decisions across the network.

Key facts

What you'll do

Review and triage incoming customer feedback related to qualification criteria, medical necessity logic, documentation requirements, and payer policy interpretation to determine the true nature of each escalation.

Analyze custom criteria requests by extracting clinical requirements and translating them into clear, structured internal guidance for criteria writers, reviewers, and customer-facing teams.

Read and interpret payer policies, Medicare and Medicaid guidance, and customer-provided clinical documentation to validate that criteria align with the correct payer, code, policy source, and specific clinical scenario.

Partner with internal stakeholders to resolve criteria-related escalations, close the loop on customer feedback, and ensure that decisions are consistently documented and communicated.

Identify recurring feedback themes and trends to drive improvements in internal criteria standards, review guidance, and escalation processes over time.

Validate alignment between customer preferences, workflow variations, and actual payer policies to prevent miscommunication and inappropriate criteria changes.

Assess documentation completeness and medical necessity rationale to determine whether gaps exist and whether they can be resolved through clarification or additional information requests.

Collaborate with cross-functional teams to escalate complex or ambiguous cases that require deeper policy review or coordination with product and clinical operations.

Maintain detailed records of escalations, decisions, and rationales to support audit readiness, quality assurance, and continuous process improvement.

Serve as a subject matter expert for the Qualifications product by providing training, feedback, and process suggestions that enhance team-wide understanding of criteria and policy.

Monitor policy updates and guidance changes from payers to ensure that internal criteria and escalation responses remain current and accurate.

Support the development of internal playbooks and decision trees that standardize how common criteria issues are evaluated and resolved.

Contribute to refining escalation workflows to reduce resolution time and improve both internal efficiency and customer satisfaction.

Act as the primary point of contact for nuanced qualification scenarios, ensuring that responses are consistent, evidence-based, and aligned with best practices.

Requirements

Active RN or LPN license is mandatory for this position and must be verifiable.

Experience in utilization management, prior authorization, medical necessity review, clinical appeals, payment integrity, CDI, payer policy review, or DME/HME qualification review is required.

Strong understanding of medical necessity, payer policy, and clinical documentation is essential to distinguish policy-backed requirements from customer preference or workflow variation.

Demonstrated strong written communication skills, attention to detail, and sound judgment in deciding when to resolve issues, when to document concerns, and when to escalate further.

Familiarity with LCDs, NCDs, HCPCS, CPT, and ICD-10 coding is a plus, as is experience with denial review or criteria-heavy workflows such as DME/HME, infusion, or specialty pharmacy.

Ability to read complex payer policies, Medicare and Medicaid guidance, and customer documentation to accurately interpret requirements and validate alignment.

Comfortable working independently and as part of a collaborative team in a fast-paced, high-impact healthcare operations environment.