Durable Medical Equipment Director

The Durable Medical Equipment (DME) Director will evaluate high-cost DME requests to determine medical necessity, ensure compliance with Medicaid guidelines, and support clinical teams in the delivery of appropriate care. This role also contributes to policy development, staff training, and performance improvement initiatives related to DME services.

Essential Functions:

Conduct clinical reviews of high-dollar DME requests including custom wheelchairs, prosthetics, orthotics, and specialty seating to assess for medical necessity, functionality, and adherence to guidelines

Collaborate with interdisciplinary teams including physicians, therapists, and equipment vendors to ensure appropriate and timely DME provision

Serve as a clinical resource to utilization management, prior authorization, and appeals teams

Educate DME providers and ordering clinicians on Medicaid coverage criteria, documentation requirements, and authorization processes

Develop and deliver internal and external training sessions related to DME regulations, medical necessity standards, and evolving best practices

Assist in the creation, evaluation, and revision of medical policies and clinical guidelines related to DME services

Identify opportunities for process improvement, cost containment, and improved member outcomes related to DME utilization

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

Lead the development of a dedicated DME clinical review unit, including staffing, workflow design, and quality assurance protocols

Support performance measurement, reporting, and compliance initiatives within the department

Perform any other job duties as requested

Education and Experience:

Bachelor's degree in occupational therapy (BSOT) with a minimum of eight (8) years of clinical experience is required

A minimum of five (5) years of experience working in Managed Medicaidwith a focus on utilization management, DME, or clinical operations is required

A minimum of three (3) years of direct experience in DME-related services including wheelchair seating, prosthetics, or adaptive equipment is required

Prior leadership or program development experience is required

Experience with InterQual or MCG criteria is preferred

Experience in policy development, clinical review systems, or appeals processing is preferred

Competencies, Knowledge and Skills:

Strong understanding of Medicaid regulations, authorization processes, and clinical documentation requirements.

Excellent communication and collaboration skills across clinical and non-clinical teams

Basic Microsoft Word skills

Excellent communication skills, both written and oral

Ability to work well independently and within a team environment

Ability to create strong relationships with Providers and Members

High ethical standards

Attention to detail

Critical listening and systematic thinking skills

Ability to maintain confidentiality and act in the company's best interest

Ability to act with diplomacy and sensitivity to cultural diversity

Decision making/problem solving skills

Conflict resolution skills

Strong sense of mission and commitment of time, effort and resources to the betterment of the communities served

Licensure and Certification:

Active, unrestricted state license as a Licensed Occupational Therapist (OTR/L) is required

ATP (Assistive Technology Professional) or seating and mobility specialty certification is preferred

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

$110,800.00 - $193,800.00 CareSource takes into consideration a combination of a can