Medical Review Nurse

Verse Medical, Inc.; United States; Sur place; USD 80 000 - 90 000; Plein temps

Résumé du poste

Verse Medical, Inc. is seeking a Medical Reviewer to ensure DME orders comply with CMS regulations, LCDs, and LCAs, acting as the bridge between policy requirements and operational excellence.

You will review medical records for medical necessity, educate providers on coverage criteria, and safeguard PHI while adhering to HIPAA standards in a fast-paced environment.

This role offers a meaningful opportunity to advance at-home care and improve the accuracy of medical billing in the United States.

Qualifications

• 3-5+ years of experience with DME pre-authorizations, DME utilization management reviews and/or DME claim audit processes.
• Proficiency with medical review software/EHR platforms.
• Excellent written and verbal communication skills with the ability to convey complex policy requirements clearly.

Responsabilités

• Medical Necessity & Compliance Review: Review DMEPOS orders, progress notes, and medical records against coverage policies to confirm medical necessity across diverse DME categories.
• Provider Education: Communicate findings clearly with healthcare providers and internal teams to bridge documentation gaps and educate stakeholders on evolving coverage criteria.
• Data Security: Maintain strict compliance with HIPAA and enforce disciplined handling of PHI across all workflows.

Connaissances

Communication skills

HIPAA compliance

Team collaboration

Adaptability

Outils

EHR platforms

Description du poste

Our Mission: Hospital-Quality Care, Everywhere.

The healthcare industry still relies on faxes and phone tags to coordinate critical care for patients at home. We think patients and the clinicians who serve them deserve better than a system stuck in 1995.

Verse Medical is building the modern software infrastructure to make it happen. We're a well-funded Series C company (backed by General Catalyst, SignalFire, and Sapphire Ventures) on a mission to heal a fragmented system. Our platform connects the dots between providers, payors, and patients, ensuring people get the high-quality care they need, reliably and right where they live. We’re growing fast and looking for people who are driven by this mission to join us!

Our Values: The Principles That Guide Us

Our values are the operating system for how we work together and with our partners. They aren't just words on a wall; they are the principles we bring to every decision, every day.

• We are transparent, upfront and direct. We operate with honesty and clarity. We share information openly, the good and the bad, and believe that direct, respectful feedback is the foundation of trust and progress.
• We value speed of iteration. We are building something new, which means we learn by doing. We prioritize rapid iteration and getting solutions into the hands of users, believing that progress is more valuable than perfection.
• We give 110% effort, 30% of the time. We are passionate about our mission, and there are moments that require us to go the extra mile. We believe in focused intensity when it counts, balanced by a sustainable pace that keeps our team energized for the long run.
• We empathize with customers to a fault. When our users face a problem, we own it. Instead of asking them to change, we ask ourselves, "How can we make this better?" We believe true innovation comes from deep empathy and a relentless focus on solving the real-world challenges of healthcare.

About The Role

This isn't just a job; it's an opportunity to build something that truly matters and directly shape the future of at-home care. As our Medical Reviewer, you will play a critical, hands-on role in ensuring that every durable medical equipment (DME) order is fully compliant with Centers for Medicare & Medicaid Services (CMS) regulations, including Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) You will serve as the bridge between complex policy requirements and operational excellence, directly safeguarding our compliance integrity and billing quality.

Key Responsibilities

• Medical Necessity & Compliance Review: Review DMEPOS orders, progress notes, and medical records against coverage policies to confirm medical necessity across diverse DME categories (e.g., Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, CPAP/PAP therapy, Ventilators, Wheelchairs, etc.).
• Provider Education: Communicate findings clearly with healthcare providers and internal teams to bridge documentation gaps and educate stakeholders on evolving coverage criteria.
• Data Security: Maintain strict compliance with HIPAA and enforce disciplined handling of Protected Health Information (PHI) across all workflows.

Required Qualifications

• Prior experience (3 - 5+ years) with DME pre-authorizations, DME utilization management reviews and/or DME claim audit processes.
• Standard computer literacy and proficiency with medical review software/EHR platforms.
• Excellent written and verbal communication skills with the ability to convey complex policy requirements clearly.
• Proven ability to thrive in a fast-paced environment with a flexible, adaptable mindset.
• Strong team player with a highly collaborative work style.
• Strict adherence to PHI guidelines and patient privacy protocols.

Preferred Qualifications

• Familiarity with InterQual and/or MCG review criteria.
• Experience in reviewing specific DME claims, including Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, CPAP/PAP therapy.

Our Pledge for an Equitable Future

At Verse Medical, our mission is to deliver equitable, hospital-quality care to everyone, regardless of their background or where they live. We can only achieve this if our own team reflects the diversity of the patients we serve. We are committed to building a workplace where everyone feels a sense of belonging, where their contributions are valued, and where they can do their best work. We embrace diversity of all kinds: race, gender, age, religion, identity, experience. We are actively working to build a more inclusive and equitable world, starting from within our own walls. We are an equal opportunity employer.

We are also committed to providing a positive and accessible interview experience. If you require any accommodations to participate in our process, please contact us at [e-mail].

Compensation Range: $80K - $90K