As a Concept Development Analyst, you will lead the identification, creation, and implementation of innovative solutions in the healthcare billing and coding field. Collaborating with a technical engineer, you will contribute to the development of data-driven queries aligned with billing policies and regulatory guidelines, such as those outlined in the CMS Medicare Claims Processing Manual. 

This role involves analyzing healthcare billing rules, translating them into actionable queries, and supporting audit and recovery initiatives. You will take ownership of each query, seeing it through the entire workstream—from initial concept development and data analysis to implementation, monitoring, and refinement based on updated bill rules and regulations. 

Leveraging your expertise in Medicare regulations, provider billing practices, and data analysis, you will assist in creating novel strategies to enhance claim selection processes, particularly in data mining and automated reviews. Your knowledge of the Medicare Claims Processing Manual, prospective payment systems, provider fee schedules, and coding guidelines will be critical in optimizing proprietary tools to ensure the highest level of payment integrity for our clients. 

Strong organizational skills, a deep understanding of payment policies, and proficiency in data analysis will drive the success of this role. Working closely with senior team members, you will refine and implement advanced approaches to improve claim selection methodologies. Additional responsibilities include monitoring query outputs, evaluating audit performance outcomes, and investigating discrepancies or variances. 

This role is dedicated to serving government payers and plays a vital part in supporting program integrity and compliance while ensuring the success of queries throughout their lifecycle. 

• Spearheads 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.
• Leads the effort to identify coding and billing logic development opportunities.
• Utilizes healthcare and auditing experience to investigate, identify and define coding and/or billing issues.
• Determines audit procedures, selection methods of found audit opportunities.
• Collaborates with engineering, analytics, audit teams, client management, and senior concept development team members to complete routine tasks.
• Leads the education and training to Training, Medical Directors, and audit leaders on audit opportunities independently found or assigned.
• Communicates results with senior team members and managers effectively.
• Demonstrates the ability to expand concepts based on customer requirements with a strong focus on concept approval.
• Proficient with Medicare reimbursement methodologies, coding and billing guidelines and applicable industry-based standards.
• Demonstrates ability to monitor and update concept criteria and logic frequently 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.
• Assists with ongoing review of all concepts prior to and after client approval.
• Creation and maintenance of concept validation procedures to include: scheduled validation of all concepts including reference and documentation, monitoring of concept performance to assist in early identification of issues and review of all associated concept documentation.
• With proficiency, utilizes internal and external tools to evaluate, document and validate new ideas, claims, and concept effectiveness.
• Assists team with ensuring that any new and existing concepts are achieving 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. 

• Bachelor’s or graduate degree preferred; equivalent related health field experience will additionally be considered.
• Minimum of 5 years of experience in medical billing, inpatient or outpatient coding, auditing, finance, or accounting. 
• Proficiency with Medicare reimbursement methodologies, billing guidelines, and applicable industry-based standards required; revenue cycle specialist experience desired. 
• Proven experience in data mining and analysis, preferably within a healthcare or audit environment. 
• AAPC or AHIMA certification (e.g. coding, revenue cycle) preferred. 
• Expertise with researching and interpreting the Medicare Claims Processing Manual, healthcare claim adjudication standards and procedures. 
• Strong understanding of Medicare data fields and their application in identifying billing and coding discrepancies. 
• Proficiency in Microsoft Excel is required, e.g. navigate pivot tables, create basic formulas (e.g. VLOOKUP). Able to conduct basic data analyses independently. 
• Proficiency in data analysis tools and software, such as SQL, SAS, or similar preferred. 
• 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, recognize and quickly shift priorities, and document progress required. 
• Prior auditing or consulting experience desirable in either a provider or payer environment.
• Experience with ChatGPT 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 per year. 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: 01/06/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 03/06/2025, 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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