DME Documentation Criteria Reviewer

Hike Medical Inc.; San Francisco (CA); On-site; USD 60,000 - 80,000; Full time

Job summary

Hike Medical Inc. is seeking a DME Documentation Criteria Reviewer to ensure compliance with medical necessity requirements and review patient documentation. In this role, you will identify gaps in documentation and collaborate closely with clinicians.

The ideal candidate will have over 3 years of experience in DMEPOS documentation review, a strong grasp of CMS Local Coverage Determinations, and familiarity with payer requirements. This position offers a unique opportunity to contribute to the healthcare landscape.

Qualifications

• 3+ years of experience reviewing DMEPOS documentation in a relevant clinical or billing role.
• Solid understanding of CMS Local Coverage Determinations and Policy Articles.
• Experience with prior authorization for major payers like UHC and Aetna.

Responsibilities

• Review patient documentation per device category against CMS LCD criteria.
• Identify documentation gaps and generate deficiency notices.
• Build criteria checklists aligned with agent guides.

Skills

DMEPOS documentation review

CMS Local Coverage Determinations

Prior authorization processes

Detail-oriented

Structured checklists

Job description

About Hike Medical

Hike Medical is building the defining company in musculoskeletal care. We sit at the intersection of AI, robotics, and healthcare, operating across three product lines: a proprietary AI-vision platform that turns a 30-second, web-based foot scan into custom 3D‑printed orthotics; an AI agent platform that automates the entire DME workflow from pre‑visit processing through claims and revenue cycle; and SoleForge, our vertically integrated 3D‑printing factory producing custom medical devices at a scale the industry has never seen.

Vision

Insoles today, full DME tomorrow, bionics by 2040. Custom insoles are just the wedge. Our long‑term vision is bionics: AI‑designed, robotically manufactured orthotic and prosthetic devices at scale, replacing a fragmented, manual industry that hasn’t changed in decades. Read the full vision at bionics2040.com.

Center of Excellence

The Center of Excellence is the intelligence engine of Hike. It owns the clinical and coding knowledge that powers every AI agent — producing agent guides per code block, setting evaluation standards, informing all compliance policies, and managing the human‑in‑the‑loop team. CoE roles are the highest‑leverage positions in the company: the documents and workflows you build determine how fast we expand into new device categories.

Role

The DME Documentation Criteria Reviewer is the clinical analyst who turns medical necessity requirements into auditable, reviewable criteria sets. You review incoming patient documentation — physician notes, evaluations, prior authorization packets — against LCD criteria and payer policy, and identify exactly what is present, what is missing, and what can be obtained. You work inside our platform, and every review action you take becomes training data for the automation layer.

What You Will Do

• Review patient documentation for each 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 (e.g., UHC requirements that differ from Medicare) 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.

What We Are Looking For

• 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, comfortable with structured checklists and building 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 organizatio