Compliance & Outcomes Specialist

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. 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 http://bionics2040.com. We’re live across the industry’s largest national orthotics-and-prosthetics providers and tracking toward a $50M run rate by the end of 2026. We’ve stealthily raised $22M across Seed and Series A from top-tier investors who backed OpenAI, Anduril, and Mercury early, and we run a fast, results-first, high-ownership culture out of our SF Rincon Hill office. About the 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. The Role The 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.