DME Documentation Criteria Reviewer
Hike MedicalDigital Health company
San Francisco, United StatesMid
Indicator Ventures
RiverPark Ventures
Rosecliff Venture Partners
Operations & Strategy
About the role
TL;DR
Review patient documentation against medical necessity requirements and payer policies.
- •The DME Documentation Criteria Reviewer is a clinical analyst responsible for translating medical necessity requirements into auditable criteria sets.
- •You will review patient documentation against LCD criteria and payer policies to identify documentation gaps and ensure compliance.
- •Key Responsibilities Review patient documentation for device categories against CMS LCD criteria and payer requirements.
- •Identify documentation gaps and generate deficiency notices to clinicians.
- •Build and maintain criteria checklists per code block.
- •Audit HITL team reviews for accuracy and consistency.
- •Flag payer-specific deviations and document them.
- •Requirements 3+ years reviewing DMEPOS documentation in a clinical, billing, or utilization management role.
- •Solid understanding of CMS Local Coverage Determinations and Policy Articles for O&P and DME categories.
- •Experience with prior authorization at Medicare FFS and major commercial payers.
- •Detail-oriented with experience in structured checklists and systematic review processes.
Required skills
Project ManagementSQLExcelJiraConfluencePowerPoint
Domain expertise
healthcare
Tech stack
PythonJavaScriptSQLGitLinuxJiraConfluenceExcelPowerPointGoogle AnalyticsGA4Looker StudioWorkdayGreenhouseLeverMarketo