Medical Reviewer, Surgical Dressings

Verse Medical

1d • Remote

About The Position

Verse Medical is building modern software infrastructure to connect providers, payors, and patients, ensuring people get high-quality care reliably at home. This role is crucial in ensuring surgical dressing orders are compliant with CMS regulations, translating policies into practical rules, and managing appeals processes. The goal is to heal a fragmented healthcare system by providing hospital-quality care everywhere.

Requirements

• 3-5+ years medical-review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto).
• Hands-on adjudication of surgical dressings (A6021 collagen; A6196–A6199 alginate/fiber‑gelling; A6209–A6199 foam; A6212–A6214 bordered foam; A6216–A6221 gauze; A6257–A6259 film).
• Expert with proof-of-delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales (e.g., two-cover stacking, over-frequency without rationale, DOS/POD mismatch).
• Crisp, policy-anchored writing.
• Calm under deadline.
• Disciplined with PHI.
• Authorized to work in the United States.

Nice To Haves

• Most of our interview process is focused on your practical experience with the coverage guidelines.

Responsibilities

• Ensure each surgical dressing order is fully compliant with every CMS regulation, including regulation/ policies as they are applied by MACs & UPICs.
• Translate LCDs/ Articles and MAC playbooks into checklists.
• Fix packet defects pre-bill.
• Run ADRs/appeals processes.
• Interpret and operationalize LCD L33831 + Policy Article for surgical dressings; publish practical rules (when covered, limits, documentation phrases).
• Stand up “go/no‑go” criteria for collagen, alginate/fiber‑gelling, foam, film, hydrocolloid; codify A‑modifier (wound count) usage, KX/GA/GZ/EY, sizing, quantity/frequency math.
• Build a 2‑gate QA (1: clinical completeness; 2: billing correctness) and pilot it on all surgical‑dressing claims.
• Create/upgrade templates for various outreach.
• Lead UPIC/MAC ADR responses (pre- and post-pay).
• Coach internal billing team; establish a reusable appeals library with policy citations and exemplars.
• Train customer-facing team members (30-min modules) and billers on the specific documentation that satisfies the LCD.
• Define and track metrics: initial denial %, appeal win %, ADR turnaround, % packets with signed POD, top-defect Pareto.

Benefits

• Up to $105,000 base salary
• 100% of your health insurance premium covered
• Access to high-quality dental and vision insurance plans for you and your dependents
• 401(k) plan
• Opportunities for rapid career advancement

What This Job Offers

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