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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
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