Medical Reviewer

This isn't just a job; it's an opportunity to build something that truly matters and directly shape the future of at-home care. As our Medical Reviewer, you will play a critical, hands-on role in ensuring that every durable medical equipment (DME) order is fully compliant with Centers for Medicare & Medicaid Services (CMS) regulations, including Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs). You will serve as the bridge between complex policy requirements and operational excellence, directly safeguarding our compliance integrity and billing quality.

Key Responsibilities

• Medical Necessity & Compliance Review: Review DMEPOS orders, progress notes, and medical records against coverage policies to confirm medical necessity across diverse DME categories (e.g., Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, CPAP/PAP therapy, Ventilators, Wheelchairs, etc.).

• Provider Education: Communicate findings clearly with healthcare providers and internal teams to bridge documentation gaps and educate stakeholders on evolving coverage criteria.

• Data Security: Maintain strict compliance with HIPAA and enforce disciplined handling of Protected Health Information (PHI) across all workflows.

Required Qualifications

• Prior experience (3 - 5+ years) with DME pre-authorizations, DME utilization management reviews, and/or DME claim audit processes.

• Standard computer literacy and proficiency with medical review software/EHR platforms.

• Excellent written and verbal communication skills with the ability to convey complex policy requirements clearly.

• Proven ability to thrive in a fast-paced environment with a flexible, adaptable mindset.

• Strong team player with a highly collaborative work style.

• Strict adherence to PHI guidelines and patient privacy protocols.

Preferred Qualifications

• Familiarity with InterQual and/or MCG review criteria.

• Experience in reviewing specific DME claims, including Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, CPAP/PAP therapy.