In the role of Concept Development Analyst within our Clinical Chart Validation organization, you will lead in the identification, creation, and implementation of innovative concepts within the healthcare billing and coding field. Drawing from your industry experience and knowledge of clinical practices and regulations, you will assist in the development of novel strategies to enhance our claim selection processes. Your proficiency in data analysis, organizational skills, and understanding of claim selection methods in conjunction with extensive knowledge of Medicare and Commercial payer requirements associated with Inpatient, Outpatient, and Physician based healthcare payment systems and billing & coding guidelines; will be essential in supporting the team's objectives that include optimizing proprietary tools to ensure the highest payment integrity for our clients. 

Working collaboratively with senior team members, you will play a key role in refining and implementing groundbreaking approaches that contribute to the advancement of our claim selection methodologies. This role is responsible for the research and creation of new audit opportunities based upon client coverage policies, monitoring query output, audit performance outcomes, and investigation of discrepancies or variances. 

• Lead the exploration, generation, and execution of pioneering concepts across various healthcare provider settings by leveraging your in-depth insights into healthcare billing and coding practices, clinical insights, and regulatory knowledge. 

• Identify and implement coding and billing logic development opportunities. 

• Utilizes healthcare and auditing experience to investigate, identify and define coding and/or billing issues. 

• Determine audit procedures, selection methods for identified audit opportunities. 

• Collaborates with engineering, analytics, audit teams, client management, and senior concept development team members to obtain alignment and drive results. 

• Educate and train Audit Operations leaders and Medical Directors on identified audit opportunities. 

• Communicates results effectively with senior team members and managers. 

• Expand concepts based on customer requirements with a strong focus on concept approval. 

• Demonstrate proficiency with Medicare reimbursement methodologies, coding and billing guidelines and applicable industry-based standards. 

• Monitor and update concept criteria and logic to reflect any changes in legislation, rules, and policies. 

• Fosters and implements new ideas, approaches, and technological improvements to support and enhance audit production, communication and client satisfaction. 

• Review all concepts before and after client approval. 

• Create and maintain concept validation procedures including scheduled validation of all concepts, monitoring concept performance, and reviewing associated documentation. 

• Utilize internal and external tools to evaluate, document, and validate new ideas, claims, and concept effectiveness. 

• Ensure new and existing concepts achieve desired goals in terms of recoveries, collectability and client acceptance. 

• Complete all responsibilities as outlined on annual Performance Plan.  

• Complete all special projects and other duties as assigned.  

• Registered Nurse required, Bachelor’s or Graduate degree preferred.  

• AAPC or AHIMA coding certification preferred. 

• Minimum of 5 years of experience in medical billing, inpatient and outpatient coding, auditing, or CDI. 

• Proficiency in at least one and desire to learn others as needed: Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Emergency Room, Behavioral Health. 

• Proficiency in Microsoft Excel required; e.g. navigate pivot tables, create basic formulas (e.g. Vlookup). Able to conduct basic data analyses independently. 

• Mastery of healthcare coding systems and payment methodologies (CPT, HCPCS, and ICD-10, HIPPS, Revenue Codes, etc.). 

• Proficient with healthcare claim adjudication standards and procedures. 

• Excellent verbal and written communication skills. 

• Strong analytical and investigative skills. 

• Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements. 

• Ability to work independently, prioritize tasks, and document progress. 

• Prior auditing or consulting experience in either a provider or payer environment is desirable. 

• Experience with ChatGPT, Copilot, or similar AI tools preferred. 

Mental Requirements: 

• Communicating with others to exchange information. 

• Assessing the accuracy, neatness, and thoroughness of the work assigned. 

Physical Requirements and Working Conditions: 

• Remaining in a stationary position, often standing or sitting for prolonged periods. 

• Repeating motions that may include the wrists, hands, and/or fingers. 

• Must be able to provide a dedicated, secure work area. 

• Must be able to provide high-speed internet access/connectivity and office setup and maintenance. 

Base compensation ranges from $95,000 to $120,000. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration.

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

Date of posting: 11/11/2024

Applications are assessed on a rolling basis. We anticipate that the application window will close on 12/31/2024, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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