Apply on Employer Site

Hike Medical · 2 days ago

Head of RCM Systems & AI Compliance

Boston, MA

Full-time

Onsite

Mid, Senior Level

$100K/yr - $140K/yr

Hike Medical is reinventing musculoskeletal care through an AI-vision platform that creates custom 3D-printed insoles. The Head of RCM Systems & AI Compliance will own compliance logic and human-in-the-loop architecture for AI agents, ensuring regulatory rules are effectively translated into systems and workflows.

Computer VisionHealth CareMachine LearningSoftware

Responsibilities

Own and define the rulesets governing AI behavior across: Eligibility & benefits verification, Prior authorization, Referrals and documentation requirements, Medical necessity validation, Claims submission, denials, and appeals

Translate payer and Medicare requirements into: Structured rules, Decision trees, Validation logic, Agent instructions

Identify and encode real-world exceptions, workarounds, and edge cases

Continuously audit AI workflows against regulatory and payer requirements

Design HITL workflows that sit directly inside AI-driven processes

Define escalation thresholds based on confidence, risk, and compliance impact

Perform hands-on review and correction of AI output to: Validate accuracy, Train and refine systems, Identify failure modes

Establish quality metrics tied to regulatory exposure, not vanity accuracy

Work directly with engineering to: Implement deterministic rules alongside AI systems, Design feedback loops between human review and agent behavior, Build tools that support rapid iteration and auditability

Serve as the domain authority for how AI should behave inside regulated workflows

Partner directly with customer RCM and compliance teams to: Understand their existing workflows, Surface edge cases and payer-specific nuances, Coordinate on escalations and compliance interpretation

Stay deeply embedded in O&P and DME operational reality

Design and build the HITL function from first principles

Hire, train, and lead HITL specialists as volume and complexity increase

Define operating procedures, escalation models, and performance standards

Build systems that reduce human involvement over time while increasing reliability

Qualification

RCM expertiseDME knowledgeO&P experienceMedicare workflowsCompliance systemsEligibility verificationPrior authorizationClaims submissionSystems thinkingTeam buildingBuilder mindset

Required

Deep, hands-on RCM and compliance expertise in DME and/or O&P

Real operating experience with Medicare-heavy workflows

Working understanding of how rules are applied in practice

Experience with eligibility checks, prior authorizations, documentation requirements, medical necessity reviews, claims submission, denials, and payer follow-ups in DME or O&P

Significant hands-on experience in DME and/or O&P revenue cycle management

Deep working knowledge of Medicare eligibility and benefits

Deep working knowledge of prior authorization workflows

Deep working knowledge of referrals and documentation standards

Deep working knowledge of medical necessity logic

Deep working knowledge of claims submission, denials, and appeals

Demonstrated ability to interpret and apply complex rules in ambiguous situations

Strong systems thinking and comfort working with engineers

Willingness to operate as a senior IC while building toward a leadership role

Builder mindset with high ownership and accountability