DME Criteria & Documentation Analyst

Hike Medical; San Francisco (CA); On-site; USD 90,000 - 145,000; Full time

Job summary

Hike Medical is seeking a DME Documentation Criteria Reviewer to audit incoming patient documentation (physician notes, evaluations, prior authorization packets) against LCD criteria and payer policies. You will identify gaps, document deficiencies, and help streamline the automation layer within our platform.

Ideal candidates have 3+ years in DMEPOS documentation review, strong CMS LCD knowledge, and prior authorization experience with Medicare and major payers.

Qualifications

• 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 with structured checklists and ability to build systematic review processes.
• Familiarity with HCPCS L-code ranges for orthotics and prosthetics preferred.
• Experience at a DMEPOS supplier, O&P company, or managed care organization.

Responsibilities

• Review patient documentation for 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 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.

Skills

CMS LCD criteria

Payer policy

Documentation review

Structured checklists

Attention to detail

Job description

Hike Medical is seeking a DME Documentation Criteria Reviewer to audit incoming patient documentation (physician notes, evaluations, prior authorization packets) against LCD criteria and payer policies. You will identify gaps, document deficiencies, and help streamline the automation layer within our platform.

Ideal candidates have 3+ years in DMEPOS documentation review, strong CMS LCD knowledge, and prior authorization experience with Medicare and major payers.