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Job description
Manhattan, NY | Hybrid (3 days in-office; 2 days remote) | $48–$58/hour | W-2 Contract-to-Hire
Medix is partnering with a growing healthcare technology company to hire a Clinical Criteria & Escalations Lead.
This is a senior individual-contributor role focused on the difficult clinical and payer questions that do not fit neatly into a standard workflow.
The person in this role will review complex cases, research coverage requirements, interpret clinical documentation, and help determine whether an issue stems from payer policy, missing evidence, workflow design, system behavior, or another operational factor.
We are open to several clinical backgrounds. What matters most is strong clinical judgment, payer-
policy knowledge, critical thinking, and the ability to turn complicated requirements into clear recommendations!
What you'll do
Evaluate complex questions involving medical necessity, clinical documentation, authorization requirements, and coverage criteria
Interpret Medicare, Medicaid, and commercial payer policies, including LCDs and NCDs when applicable
Review medical records and determine whether the available documentation supports coverage requirements
Investigate escalated cases and identify the underlying issue
Evaluate requests for customized clinical criteria and recommend an appropriate approach
Translate complex payer and clinical requirements into clear, consistent guidance
Partner with clinical, operations, implementation, and product teams on escalated questions
Identify recurring issues and recommend improvements to workflows, documentation standards, and review processes
Develop and refine internal guidance, review protocols, and SOPs
Clearly document findings, rationale, and supporting sources
What we're looking for
Relevant backgrounds may include nursing, occupational therapy, physical therapy, pharmacy, or another healthcare discipline with significant experience in payer policy, medical necessity, or clinical review.
Strong candidates will have experience in one or more of the following:
Medical necessity review
Clinical appeals
Payer policy or coverage review
Clinical documentation improvement
Payment integrity
Clinical quality review
You should also be comfortable:
Independently researching payer requirements
Working through ambiguous or conflicting information
Separating missing documentation from a true failure to meet criteria
Explaining the reasoning behind a recommendation
Reviewing complex clinical records
Collaborating with both clinical and non-clinical teams
Learning new technology and workflows quickly
Preferred experience
Experience with DME/DMEPOS, home health, rehabilitation or mobility services, infusion, specialty pharmacy, imaging, or other specialized healthcare services is especially valuable.
Familiarity with Medicare/Medicaid coverage policy, LCDs/NCDs, HCPCS, CPT, ICD-10, denials/appeals, clinical criteria development, QA, audit tools, workflow design, or healthcare technology is also highly relevant.
$48–$58/hour
W-2 contract-to-hire through Medix
Approximately 800 working hours / 4–5 months
Monday–Friday, 9:00 AM–6:00 PM ET
Hybrid in Manhattan with regular onsite collaboration (3 days in-office; 2 days remote)
Weekly payroll
Benefits available through Medix after 30 days
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Worksite address
new york, NY, 10261, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.