DME Documentation Criteria Reviewer

Hike Medical

DME Documentation Criteria Reviewer analyzing patient documentation for compliance with CMS criteria and payer's requirements. Collaborating with clinical teams to enhance documentation processes.

Posted 6/29/2026full-timeSan Francisco • California • 🇺🇸 United StatesMid-LevelSenior💰 $90,000 - $145,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in reviewing DMEPOS documentation against CMS Local Coverage Determinations and payer-specific requirements, with a strong focus on prior authorization processes and attention to detail in systematic review methodologies.

Highest-signal resume keywords

DMEPOS Documentation ReviewCMS Local Coverage DeterminationsPrior Authorization ExperienceDetail-OrientedHCPCS L-Code Familiarity

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Documentation ReviewCriteria Checklist DevelopmentAudit ProcessesDeficiency Notice GenerationPrior Authorization Mapping

Soft Skills

CollaborationAttention to Detail

Industry Keywords

DMEPOSO&PUtilization ManagementMedicare FFSManaged Care Organization

Tech Stack

Tools & technologies

Assembly

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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 (UHC, Aetna, Cigna).
Detail-oriented, comfortable with structured checklists and building systematic review processes.
Familiarity with HCPCS L-code ranges for orthotics and prosthetics preferred.
Experience at a DMEPOS supplier, O&P company, or managed care organization

Benefits

Comp & perks

Health insurance
Stock options