The RoleThe Compliance & Outcomes Specialist is the person who knows why a claim gets denied - and what it takes to make sure it never gets denied again. You maintain full working knowledge of all relevant medical policies across CMS and major commercial payers, track how those policies evolve, and ensure every clinical protocol and agent guide we publish is grounded in current policy and supported by outcomes data. You also track external evidence - peer-reviewed articles, registry data, payer medical bulletins - and decide when that evidence should change how we build our protocols.
What You Will Do- 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.
What We Are Looking For- 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.
