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 prostheticsDevelop and deliver internal and external training sessions related to DME regulations, medical necessity standards, and evolving best practicesActively participate in interdisciplinary care management rounds, supporting complex member needs and discharge planning related to mobility and rehabilitation equipmentProvide clinical support and recommendations to case managers and care coordinatorsProvide feedback to DME Director on creation, evaluation, and revision of medical policies and clinical guidelines related to DME servicesCollaborate with utilization management, care management teams, and healthcare providers to ensure members receive medically necessary and clinically appropriate care and equipmentApply 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 prostheticsMake referrals to appropriate care management or QI if issues/concerns are identifiedComplete all aspects of the review process from initial review to peer to peer, appeals and state hearing where applicableProvide education as needed, including cross-team training, consultation, and guidance to colleagues and external stakeholders regarding DME, orthotics and prosthetics appropriatenessWork closely with senior leadership to identify and provide feedback on ways to implement and improve the review process for DME, orthotics and prostheticsStrive for excellence in compliance with policies and standardsPerform any other job duties as requestedEducation and Experience:Bachelor's degree Occupational Therapy, Physical Therapy or Speech Therapy requiredA minimum of four (4) years of experience of direct patient care with focus on rehabilitative DME or a related field is requiredUtilization management experience is preferredCompetencies, Knowledge and Skills:Advanced knowledge of rehabilitative DME and/or orthotics and prosthetics preferredBasic data entry skills and internet utilization skillsWorking knowledge of Microsoft Outlook, Word, and ExcelEffective oral and written communication skillsAbility to work independently and within a team environmentAttention to detailFamiliarity of the healthcare fieldProper grammar usage and phone etiquetteTime management and prioritization skillsCustomer service orientedDecision making/problem solving skillsStrong organizational skillsChange resiliencyLicensure and Certification:Current, unrestricted state license as an Occupational Therapist, Physical Therapist or Speech Therapist is requiredMCG Certification is required within 6 months of hireWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeCompensation 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 individ

Created: 2025-12-05