Hike Medical
Compliance & Outcomes Specialist
San Francisco, CA
Sponsorship not specifiedDetected 34 days ago
AuditingRoboticsICD-10Medical Devices
About 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.
Responsibilities
- Track clinical outcomes data and peer-reviewed evidence, and advise the Protocol Specialist when evidence should drive protocol changes.
- AI-designed, robotically manufactured orthotic and prosthetic devices at scale, replacing a fragmented, manual industry that hasn't changed in decades.
- 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.
Requirements
- Working knowledge of the CMS LCD and Policy Article framework, the CMS Required Prior Authorization List, and major commercial payer policies.
- Familiarity with appeals and redetermination at Medicare FFS and major commercial payers.
- Ability to synthesize clinical evidence into policy-relevant summaries.
Benefits
- Read the full vision at bionics2040.com http://bionics2040.com.
- 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.
- Map ICD-10 codes to qualifying coverage criteria for each device category, and maintain those mappings as policy evolves.
- Support appeals and redetermination: when a claim is denied, define the documentation and medical necessity argument behind the appeal.
- 5+ years in healthcare compliance, medical policy, utilization management, or clinical documentation auditing in a DMEPOS or O&P context.
- Experience reviewing ICD-10 to HCPCS mappings for coverage accuracy.
- Background at a DMEPOS supplier, O&P company, managed care organization, or payer medical policy team.
Company info
- the documents and workflows you build determine how fast we expand into new device categories.
- 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.
- 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.
- Monitor policy changes - CMS transmittals, Medicare Advantage updates, LCD revision cycles - and flag impacted agent guides for update within SLA.
- 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
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This listing is sourced directly from Hike Medical's careers page and normalized into a canonical job model.