Clinical Criteria Escalations Specialist

This full-time position involves managing customer feedback and clinical escalations for a team that evaluates medical necessity. The specialist will triage issues to determine if they stem from criteria errors, payer policy interpretations, documentation gaps, or specific client preferences. You will translate complex clinical requirements into clear guidance for internal writers and customer-facing staff. The role requires interpreting payer policies, Medicare and Medicaid rules, and clinical documents to ensure accuracy. Candidates should be comfortable analyzing ambiguous feedback using strong clinical judgment. The employer seeks an RN or LPN with a background in utilization management, prior authorization, clinical appeals, or medical necessity review. No specific language proficiency is mentioned in the provided text. The job is performed remotely. This opportunity suits nursing professionals who have experience reviewing clinical documentation and navigating payer policy complexities.