Medical Review Nurse

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.

About the Role

This isn't just a job; it's an opportunity to build something that truly matters and directly shape the future of at-home care. As our Medical Reviewer, you will play a critical, hands-on role in ensuring that every durable medical equipment (DME) order is fully compliant with Centers for Medicare & Medicaid Services (CMS) regulations, including Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) You will serve as the bridge between complex policy requirements and operational excellence, directly safeguarding our compliance integrity and billing quality.

Key Responsibilities

Medical Necessity & Compliance Review: Review DMEPOS orders, progress notes, and medical records against coverage policies to confirm medical necessity across diverse DME categories (e.g., Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, CPAP/PAP therapy, Ventilators, Wheelchairs, etc.).

Provider Education: Communicate findings clearly with healthcare providers and internal teams to bridge documentation gaps and educate stakeholders on evolving coverage criteria.

Data Security: Maintain strict compliance with HIPAA and enforce disciplined handling of Protected Health Information (PHI) across all workflows.

Required Qualifications

Prior experience (3 - 5+ years) with DME pre-authorizations, DME utilization management reviews and/or DME claim audit processes.

Standard computer literacy and proficiency with medical review software/EHR platforms.

Excellent written and verbal communication skills with the ability to convey complex policy requirements clearly.

Proven ability to thrive in a fast-paced environment with a flexible, adaptable mindset.

Strong team player with a highly collaborative work style.

Strict adherence to PHI guidelines and patient privacy protocols.

Preferred Qualifications

Familiarity with InterQual and/or MCG review criteria.

Experience in reviewing specific DME claims, including Surgical Dressings, CGMs, Insulin Pumps, Wound Care, Ostomy, Urology, CPAP/PAP therapy.

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.