DME Documentation Criteria Reviewer

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 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