- Project Management
- Microsoft Word
- Medical Coding Certification
Conducts thorough research and analysis for medical policy items
Performs multi-faceted analytics for data and report analysis
Responsible for translating industry references into Cotiviti policy
Reviews and identifies changes to medical policies in order to maintain an accurate and current medical policy library
Identifies new opportunities as appropriate from both clinical reference and analytical sources
Analyzes research inquiries from a multitude of sources and applies solid clinical judgment to determine potential impact to medical policies
Ability to determine if an update to existing policy logic or content is warranted based on changes to industry or Cotiviti reference data
Performs QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy. In addition to QA, provides feedback to originator as needed.
Educates client-facing Medical Directors (MDs) and Client Policy Managers (CPMs) on new changes and policy updates by actively participating in monthly meetings for client facing MDs and CPMs
Manages interactions with our expert panel (consultant pool) on relevant clinical issues
Ensures work is accurate, complete and finished in a timely manner including documentation of notable changes.
Maintains current knowledgebase of industry and Cotiviti content, best practices, applications, procedures and policies
Other Related Responsibilities
Drives and supports the vision and values of Cotiviti and abides by all company policies and procedures.
Improves and implements procedures as needed and/or assigned.
Consistently provides optimum service to all internal and external customers.
Consistently works to develop and maintain positive and professional relationships with all internal and external customers.
Other duties as assigned
Education / Certification Requirements
Bachelors Degree (or higher) in Nursing (BSN) or Pharmacy (BSPharm or PharmD); Offshore Medical Degrees (MBBS or higher)
Professional certification (RHIA, RHIT, CPC, CPC-H, CPC-P or CCS-P) preferred or willingness to attend coding courses sponsored by the Company
Knowledge & Experience
Minimum of 5 years or experience in a clinical setting as a nurse or pharmacist or physician
Minimum of 3 years of experience in internet based research as it relates to codes (CPT, HCPCS, ICD, or NCD)
Knowledge of coding or claims adjudication in one of the following areas preferred: Pharmacy, DME or Lab
Knowledge of ICD-10 coding preferred
Experience in a health plan, PBM, Medicare or State Medicaid with focus on reimbursement and/or claims processing preferred. Equivalent experience would be knowledge through a payer services organization working with one or more of the organizations noted above.
Experience developing medical payment policy edits or algorithms (preferred)
Maintains high degree of flexibility in performing research and analysis
Responsive to learning new tools and analytical techniques
Considers rule interactions and interconnectedness of current systems
Capable of relating current system and operational responsibilities into new system and process design
Exhibits accuracy and thoroughness
Possess in depth knowledge of claims, claims adjudication, medical policy rules and edits
Strong organizational and project management experience preferred.
High attention to detail
Strong analytical, critical thinking and problem solving skills
Works with a sense of urgency
Proficient with Microsoft Office Suite (Word, Excel, Power Point); Intermediate Excel
Professional with ability to properly handle confidential information
Ability to work well independently and in a team environment.
Ability to handle multiple tasks, prioritize and meet deadlines.
Excellent written and verbal communication skills
Communicates with ease up and down the chain of leadership
This role can be located at one of our US offices or can work remotely in the continental US.
High speed internet connection (wired) is required.
Must be able to sit and use a computer keyboard for extended periods of time
Occasional travel required (primarily related to training and quarterly meetings)
Flexibility to travel outside the US based on business need is preferred
Must have ability to positively handle/manage stress, such as high work volume and frequent change
Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones.
After hours and/or weekend work required where necessary for major deliverables/deadlines (not consistent)
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.