The RoleThe 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
