Medical Review Nurse

About Verse Medical

Verse Medical aims to revolutionize healthcare coordination by replacing outdated fax and phone systems with modern software infrastructure that connects providers, payors, and patients. The company focuses on delivering hospital-quality care in patients' homes reliably and efficiently. Supported by prominent investors, Verse Medical is rapidly growing and seeks mission-driven individuals to join their team.

Company Values

• Transparent communication emphasizing honesty, openness, and respectful feedback to foster trust and continuous progress.
• Emphasis on rapid iteration and learning through action, valuing progress over perfection.
• Balanced work intensity, encouraging passionate effort during critical moments while maintaining sustainable pacing.
• Deep empathy towards customers, striving to improve systems for users rather than expecting users to adapt.

Role Overview

As a Medical Reviewer, you will influence the future of at-home care by ensuring full compliance of surgical dressing orders with CMS regulations and policies implemented by MACs and UPICs. Your responsibilities will include interpreting policy articles into actionable checklists, correcting documentation defects before billing, and managing appeals and ADR processes.

Key Responsibilities

• Translate LCD L33831 and related policy articles into practical guidance covering coverage, limitations, and required documentation.
• Establish "go/no-go" decision criteria for different surgical dressing types including collagen, alginate/fiber-gelling, foam, film, and hydrocolloids; define usage of specific modifiers and calculations for sizing and frequency.
• Develop and implement a two-stage quality assurance process focusing on clinical completeness and billing accuracy for surgical dressing claims.
• Create and update outreach templates to enhance communication and compliance efforts.
• Oversee responses to UPIC and MAC ADRs, managing both pre- and post-payment processes.
• Mentor the internal billing team and create a comprehensive appeals library with relevant policy citations and sample cases.
• Conduct training sessions for customer-facing staff and billers on documentation compliance related to LCD policies.
• Define and monitor key metrics such as denial rates, appeal success, ADR turnaround times, and identify leading causes of claim defects.

Required Experience and Expertise

• Minimum of 3 to 5 years experience in medical review within UPIC or MAC environments (such as Safeguard Services, Qlarant, CoventBridge, Noridian, CGS, NGS, WPS, Novitas, Palmetto).
• Proficient adjudication of surgical dressing claims covering products like collagen (A6021), alginate/fiber-gelling (A6196–A6199), foam (A6209–A6215), bordered foam (A6212–A6214), gauze (A6216–A6221), and film (A6257–A6259).
• Expert knowledge of proof-of-delivery criteria, SWO requirements, rules governing frequency and sizing, and familiarity with common denial reasons including cover stacking, frequency without justification, and date of service mismatches.
• Strong, policy-focused writing skills, ability to maintain composure under deadlines, and strict adherence to protecting personal health information.

Commitment to Diversity and Inclusion

Verse Medical is dedicated to creating an inclusive workplace that mirrors the diversity of the patient populations served. The company actively fosters equal opportunity and embraces differences in race, gender, age, religion, identity, and experience. Accommodations for interview participation requests are available to ensure an equitable hiring process.