[Hiring] Medical Review Nurse @Verse Medical

Role Description

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

• 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.

Qualifications

• 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).
• 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 [email protected].