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Tennr is a healthcare operations platform that automates the complex paperwork and prior authorization workflows that currently overwhelm providers and delay patient care. The company uses proprietary models to handle medical necessity documentation, payer policy interpretation, and insurance qualification requirements—helping providers get paid faster and patients access care sooner.
As a Clinical Criteria Escalations Specialist, you'll be the bridge between Tennr's customers (healthcare providers and operators) and the internal Qualifications team. You'll own the triage and resolution of customer feedback, custom criteria requests, and clinical escalations related to medical necessity, documentation requirements, and payer policy interpretation.
Key responsibilities include:
- Reviewing and triaging customer feedback to determine whether issues stem from actual criteria gaps, payer policy interpretation questions, documentation shortfalls, or customer-specific preferences
- Translating custom criteria requests into clear, actionable internal guidance for criteria writers, reviewers, and customer-facing teams
- Reading and interpreting payer policies (LCDs, NCDs), Medicare/Medicaid guidance, and clinical documentation to validate that criteria align with the correct payer, code, policy source, and clinical scenario
- Partnering with internal teams to resolve escalations and close the loop on customer feedback
- Identifying recurring themes in feedback and recommending improvements to criteria standards, review processes, and escalation workflows
You'll need an active RN or LPN license and hands-on experience in utilization management, prior authorization, medical necessity review, clinical appeals, payment integrity, CDI, payer policy review, or DME/HME qualification review. Strong clinical judgment, familiarity with healthcare coding systems (HCPCS, CPT, ICD-10), and the ability to navigate ambiguous or conflicting guidance are essential. The role is based in Tennr's Hudson Square office in Manhattan with a 4-day/week in-office expectation.
