Clinical Criteria Escalations Specialist (Medtech)

Location: Hybrid, New York City office; collaboration in the Hudson Square office 4 days per week

Salary: $95,000–$115,000 annually, plus a $10,000–$25,000 bonus

Company

hirify.global develops proprietary models that automate complex healthcare paperwork, helping providers reduce patient delays and receive payment from insurance companies.

What you will do

• Review and triage customer feedback involving qualification criteria, medical necessity logic, documentation requirements, and payer policy interpretation.
• Evaluate custom criteria requests and translate clinical requirements into guidance for criteria writers, reviewers, and customer-facing teams.
• Interpret payer policies, Medicare and Medicaid guidance, and customer documentation.
• Validate criteria against the correct payer, code, policy source, and clinical scenario.
• Partner with internal teams to resolve criteria-related escalations and improve standards, review guidance, and escalation processes.

Requirements

• 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.
• Ability to distinguish policy-backed requirements from customer preferences and workflow variations.
• Strong written communication, attention to detail, and clinical judgment around resolving, documenting, or escalating issues.

Nice to have

• Familiarity with LCDs, NCDs, HCPCS, CPT, ICD-10, denial review, DME/HME, infusion, or specialty pharmacy workflows.

Culture & Benefits

• Impact-focused work aimed at reducing patient delays across the U.S. healthcare system.
• Opportunity to develop operational expertise in scaling systems, tools, and infrastructure.
• Free lunch and an office pantry with snacks.
• Unlimited PTO and competitive parental leave.
• 100% paid employee health benefit options and an employer-funded 401(k) match.