DME Documentation Criteria Reviewer

Hike Medical • San Francisco, CA

4d • $90,000 - $145,000 • Onsite

About The Position

Hike Medical is a company at the intersection of AI, robotics, and healthcare, focused on revolutionizing musculoskeletal care. They offer a proprietary AI-vision platform for custom 3D-printed orthotics, an AI agent platform for automating DME workflows, and a vertically integrated 3D-printing factory. Their long-term vision is to produce AI-designed, robotically manufactured orthotic and prosthetic devices at scale. The Center of Excellence is the company's intelligence engine, responsible for clinical and coding knowledge that powers their AI agents. The DME Documentation Criteria Reviewer is a clinical analyst within the Center of Excellence who translates medical necessity requirements into auditable criteria sets. This role involves reviewing patient documentation against LCD criteria and payer policies, identifying documentation gaps, and providing training data for the company's automation layer.

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 (UHC, Aetna, Cigna).
• Detail-oriented, comfortable with structured checklists and building systematic review processes.
• Experience at a DMEPOS supplier, O&P company, or managed care organization.

Nice To Haves

• Familiarity with HCPCS L-code ranges for orthotics and prosthetics preferred.

Responsibilities

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed