Medical Reviewer

You will interpret and operationalize LCD L33831 + Policy Article for surgical dressings and publish practical rules (when covered, limits, documentation phrases). Stand up “go/no‑go” criteria for collagen, alginate/fiber‑gelling, foam, film, hydrocolloid and codify A‑modifier (wound count) usage, KX/GA/GZ/EY, sizing, quantity/frequency math. You will build a 2‑gate QA (1: clinical completeness; 2: billing correctness) and pilot it on all surgical‑dressing claims while creating/upgrading templates for various outreach. You will lead UPIC/MAC ADR responses (pre‑ and post‑pay) and coach internal billing team to establish a reusable appeals library with policy citations and exemplars. You will train customer-facing team members (30‑min modules) and billers on the specific documentation that satisfies the LCD. Finally, you'll define and track metrics: initial denial %, appeal win %, ADR turnaround, % packets with signed POD, top‑defect Pareto.