Compliance & Outcomes Specialist

About the role

The Compliance & Outcomes Specialist is responsible for maintaining and updating Hike's medical policy library, ensuring compliance with CMS and major commercial payer policies. This role involves monitoring policy changes, mapping ICD-10 codes to coverage criteria, and advising on protocol changes based on clinical outcomes and external evidence. Additionally, the Specialist supports appeals and redeterminations, advises on compliance risks for new category expansions, and participates in audits of the Human-in-the-Loop (HITL) team.

Responsibilities

• Maintain the Hike medical policy library: CMS LCDs/NCDs, Policy Articles, CMS Required PA List, and major commercial payer policies for all active and planned categories.
• Monitor policy changes (CMS transmittals, Medicare Advantage updates, LCD revision cycles) and flag impacted agent guides for update within SLA.
• Map ICD-10 codes to qualifying coverage criteria for each device category, and maintain those mappings as policy evolves.
• Track clinical outcomes data and peer-reviewed evidence, and advise the Protocol Specialist when evidence should drive protocol changes.
• Support appeals and redetermination: define the documentation and medical necessity argument behind the appeal.
• 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.

Requirements

• 5+ years in healthcare compliance, medical policy, utilization management, or clinical documentation auditing in a DMEPOS or O&P context.
• Working knowledge of the CMS LCD and Policy Article framework, the CMS Required Prior Authorization List, and major commercial payer policies.
• Experience reviewing ICD-10 to HCPCS mappings for coverage accuracy.
• Familiarity with appeals and redetermination at Medicare FFS and major commercial payers.
• Ability to synthesize clinical evidence into policy-relevant summaries.
• Background at a DMEPOS supplier, O&P company, managed care organization, or payer medical policy team.

Qualifications

• Master's degree in Healthcare Administration, Public Health, or related field preferred.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.
• Proficiency in Microsoft Office Suite.

Skills

• Knowledge of healthcare regulations and policies.
• Experience with ICD-10 and HCPCS coding.
• Strong attention to detail and organizational skills.
• Ability to work independently and manage multiple tasks simultaneously.

Benefits

• Competitive compensation range: $140K - $200K.
• Flexible work schedule.
• Health, dental, and vision insurance.
• 401(k) retirement plan with company match.
• Employee assistance program.
• Professional development opportunities.

Pay

• $140K - $200K

Schedule

• Full-time