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Medical Reviewer, Surgical Dressings

United States 65000.00 - 105000.00 USD / Year · Job Posted February 18, 2026
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Job Description

This isn't just a job; it's a chance to build something that matters. As DME Medical Reviewer, you'll be shaping the future of at-home care. You'll be a key part of the team, working to ensure each surgical dressing order is fully compliant with every CMS regulation, including regulation/ policies as they are applied by MACs & UPICs. You’ll translate LCDs/ Articles and MAC playbooks into checklists, fix packet defects pre‑bill, and run our ADRs/appeals processes.

Job Responsibility

  • 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

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–A6215 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

What we offer

  • Comprehensive Health & Wellness: We cover 100% of your health insurance premium and provide access to high-quality dental and vision insurance plans for you and your dependents
  • Plan for the Future: We offer a 401(k) plan to help you save for your future
  • Career Growth: You'll have opportunities for rapid career advancement in a company that's at a major inflection point

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