Maintain the Hike medical policy library: CMS LCDs/NCDs, Policy Articles, CMS Required PA List, and major commercial payer policies (UHC, Aetna, Cigna, BCBS) for all active and planned categories.
Monitor policy changes — CMS transmittals, Medicare Advantage updates, LCD revision cycles — and flag impacted agent guides for update within SLA.
Map ICD-10 codes to qualifying coverage criteria for each device category, and maintain those mappings as policy evolves.
Track clinical outcomes data and peer-reviewed evidence, and advise the Protocol Specialist when evidence should drive protocol changes.
Support appeals and redetermination: when a claim is denied, define the documentation and medical necessity argument behind the appeal.
Advise on compliance risk in new category expansions: identify payer-specific landmines before launch.
Participate in periodic audits of HITL team review accuracy against compliance standards.

5+ years in healthcare compliance, medical policy, utilization management, or clinical documentation auditing in a DMEPOS or O&P context.
Working knowledge of the CMS LCD and Policy Article framework, the CMS Required Prior Authorization List, and major commercial payer policies.
Experience reviewing ICD-10 to HCPCS mappings for coverage accuracy.
Familiarity with appeals and redetermination at Medicare FFS and major commercial payers.
Ability to synthesize clinical evidence into policy-relevant summaries.
Background at a DMEPOS supplier, O&P company, managed care organization, or payer medical policy team.

Compliance & Outcomes Specialist

About this role