DME Eligibility & Compliance Specialist

AdaptHealth, LLC; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

AdaptHealth, LLC invites a qualified professional to join as Qualification Specialist supporting DME, PAP, and oxygen therapy services. You will review medical records and physician orders to determine eligibility and medical necessity, while ensuring Medicare/Medicaid and commercial insurance adherence.

The role also involves coordinating authorizations, educations patients, and maintaining compliant documentation.

Qualifications

• Experience evaluating eligibility for DME, PAP, and oxygen therapy under Medicare/Medicaid and private insurers.
• Ability to interpret coverage criteria and coordinate documentation with providers.
• Knowledge of LCDs/NCDs and HIPAA requirements.

Responsibilities

• Evaluate eligibility and medical necessity for DME, PAP, and oxygen therapy equipment.
• Verify insurance benefits and obtain authorizations with complete clinical documentation.
• Review physician orders and sleep studies for coverage criteria.
• Ensure regulatory compliance with LCDs, NCDs, and commercial policies.
• Collaborate with physicians and clinicians to gather required information.
• Educate patients on coverage and financial responsibilities.
• Track authorizations and manage reauthorizations as needed.
• Prepare appeals with supporting clinical evidence and coordiante peer reviews.
• Support audits with documentation and records.
• Utilize EHR/portals to process qualifications and generate reports.
• Identify process improvements to shorten approval times.

Skills

Medicare/Medicaid guidelines

Regulatory knowledge

Clinical understanding

Analytical skills

Communication skills

Technology proficiency

HIPAA compliance

Independent work

Education

Associate’s degree in healthcare administration

High school diploma or equivalent

Tools

Microsoft Office Suite

Electronic health records (EHR) systems

Job description

AdaptHealth, LLC invites a qualified professional to join as Qualification Specialist supporting DME, PAP, and oxygen therapy services. You will review medical records and physician orders to determine eligibility and medical necessity, while ensuring Medicare/Medicaid and commercial insurance adherence.

The role also involves coordinating authorizations, educations patients, and maintaining compliant documentation.