Hike Medical

Reviewer

• Review patient documentation for each device category against CMS LCD criteria and payer-specific requirements.
• Identify documentation gaps and generate structured deficiency notices to clinicians and prescribers.
• Build and maintain criteria checklists per code block, aligned with the Clinical Intelligence Lead's agent guides.
• Audit HITL team reviews for criteria accuracy and consistency.
• Flag payer-specific deviations (e.g., UHC requirements that differ from Medicare) and document them in the policy library.
• Collaborate with the Protocol Specialist to update criteria sets when LCDs change.
• Support prior authorization packet assembly, ensuring each packet maps to the coverage criteria for the relevant payer.

DME Documentation Criteria Reviewer

Compliance

• Maintain the Hike medical policy library: CMS LCDs/NCDs, Policy Articles, CMS Required PA List, and major commercial payer policies (UHC, Aetna, Cigna, BCBS) for all active and planned categories.
• Monitor policy changes — CMS transmittals, Medicare Advantage updates, LCD revision cycles — and flag impacted agent guides for update within SLA.
• Map ICD-10 codes to qualifying coverage criteria for each device category, and maintain those mappings as policy evolves.
• Track clinical outcomes data and peer-reviewed evidence, and advise the Protocol Specialist when evidence should drive protocol changes.
• Support appeals and redetermination: when a claim is denied, define the documentation and medical necessity argument behind the appeal.
• Advise on compliance risk in new category expansions: identify payer-specific landmines before launch.
• Participate in periodic audits of HITL team review accuracy against compliance standards.

DME Documentation Criteria Reviewer

Compliance & Outcomes Specialist