Medical Review Nurse

Job description

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. HOW YOU'LL HELP US HEAL A BROKEN SYSTEM This isn't just a job; it's a chance to build something that matters. As Medical Reviewer, you'll be shaping the future of at-home care. You'll be a key part of the team, working to ensure each surgical dressing order is fully compliant with every CMS regulation, including regulation/ policies as they are applied by MACs & UPICs. You’ll translate LCDs/ Articles and MAC playbooks into checklists, fix packet defects pre‑bill, and run our ADRs/appeals processes. YOUR CONTRIBUTIONS Within your first year, you will have the opportunity to: - Policy → Practice - Interpret and operationalize LCD L33831 + Policy Article for surgical dressings; publish practical rules (when covered, limits, documentation phrases). - Stand up “go/no‑go” criteria for collagen, alginate/fiber‑gelling, foam, film, hydrocolloid; codify A‑modifier (wound count) usage, KX/GA/GZ/EY, sizing, quantity/frequency math. - Pre‑Bill Controls - Build a 2‑gate QA (1: clinical completeness; 2: billing correctness) and pilot it on all surgical‑dressing claims. - Create/upgrade templates for various outreach. - Audit & Appeals - Lead UPIC/MAC ADR responses (pre‑ and post‑pay). - Coach internal billing team; establish a reusable appeals library with policy citations and exemplars. - Enablement & Analytics - Train customer-facing team members (30‑min modules) and billers on the specific documentation that satisfies the LCD. - Define and track metrics: initial denial %, appeal win %, ADR turnaround, % packets with signed POD, top‑defect Pareto. SKILLS AND EXPERIENCE YOU’LL LEVERAGE We believe that diverse experiences and backgrounds lead to better solutions. While we have an idea of what will help someone succeed in this role, we are open to being convinced by your unique story and skills. If you believe you can achieve the outcomes above, we encourage you to apply. Core Skills & Experience: - 3-5+ years medical‑review experience at a UPIC or MAC (e.g., Safeguard Services, Qlarant, CoventBridge; Noridian, CGS, NGS, WPS, Novitas, Palmetto). - Hands‑on adjudication of surgical dressings (A6021 collagen; A6196–A6199 alginate/fiber‑gelling; A6209–A6215 foam; A6212–A6214 bordered foam; A6216–A6221 gauze; A6257–A6259 film). - Expert with proof‑of‑delivery standards, SWO requirements, frequency/sizing rules, and common denial rationales (e.g., two‑cover stacking, over‑frequency without rationale, DOS/POD mismatch). Most of our interview process is focused on your practical experience with the coverage guidelines. - Crisp, policy‑anchored writing; calm under deadline; disciplined with PHI. 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 recruiting@versemedical.com.