DME Clinical Advisor

Job Summary :

The DME Clinical Advisor ensures the delivery of medically appropriate durable medical equipment (DME), orthotics, and prosthetics while maintaining cost-effectiveness.

Essential Functions :

• Perform complex clinical reviews of rehabilitative DME, orthotics and prosthetics based on documentation standards from national therapy associations, best practice standards, clinical expertise, and appropriate guidelines / medical criteria.
• Provide detailed guidance to medical directors for appropriate medical necessity determination.
• Stay updated on changes in state and federal healthcare regulations, guidelines, and technologies related to DME, orthotics and prosthetics
• Develop and deliver internal and external training sessions related to DME regulations, medical necessity standards, and evolving best practices
• Actively participate in interdisciplinary care management rounds, supporting complex member needs and discharge planning related to mobility and rehabilitation equipment
• Provide clinical support and recommendations to case managers and care coordinators
• Provide feedback to DME Director on creation, evaluation, and revision of medical policies and clinical guidelines related to DME services
• Collaborate with utilization management, care management teams, and healthcare providers to ensure members receive medically necessary and clinically appropriate care and equipment
• Apply advanced clinical knowledge to address complex needs of member and other issues such as the over-utilization of services or specific types of DME, orthotics and prosthetics
• Make referrals to appropriate care management or QI if issues / concerns are identified
• Complete all aspects of the review process from initial review to peer to peer, appeals and state hearing where applicable
• Provide education as needed, including cross-team training, consultation, and guidance to colleagues and external stakeholders regarding DME, orthotics and prosthetics appropriateness
• Work closely with senior leadership to identify and provide feedback on ways to implement and improve the review process for DME, orthotics and prosthetics
• Strive for excellence in compliance with policies and standards
• Perform any other job duties as requested

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Compensation Range :

$81,400.00 - $130,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type : Salary

Competencies :

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

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