The Clinical Consultant support Clinical Services teams in the validation of quality and processes consistency on the Claims Processing Editing Engine (CPE).  

Provides support and subject matter expertise on Coding Validation (CV) to both clients and internal stakeholders during the planning, implementation, go-live, transition to operational team, and through the duration of the contract. Clearly understands and articulates CV concepts and policies. Collaborates with internal teams to provide meaningful input on CV processes, improvements, and support to maximize value and service for clients. Supports internal teams with preparation of new policy presentations and appeals management process. Supports validation of quality and process consistency including customization requests, payment policies, pre and post testing, and UAT testing.

Client facing Coding Validation support:

• Act as a liaison for clinical information between internal partners and external customers.
• Provide resources to facilitate client understanding of Coding Validation policies and concepts.
• Respond to client inquiries in a timely manner in compliance with policy and procedures.
• Review and analyze CV related client inquiries and Change Requests for clarity of intent, assessing impact of decisions for affected policies, and communicating effectively with the client to address questions or clarify information.
• Provide support and resources to clients for provider abrasion issues.
• Review and provide written and/or verbal explanation of CV coding concepts.
• Resource to client for CV related quality issues
• Appropriately and effectively communicate quality review results and revisions (if applicable) to clients when they occur.
• Provide action plans to mitigate future issues as needed with Quality Team in close internal collaboration.

 Add Value to Internal Teams:

• Proactively offer benefit of CV knowledge and experience.
• Work collaboratively with Client Teams to develop and maintain excellent client relationships.
• Collaborate and provide input from a client-based perspective on changes in edit configuration, updates to existing rules, and development of new editing.
• Assist the Clinical Content Team with feedback from a client perspective on new trends and application of new rules.
• Work with Quality, Training, and Operations Teams as needed to facilitate any updates in CV review guidelines, effectively communicate changes in client specific review, and address other CV client issues in an accurate and timely manner.
• Support resource for the Clinical Services team on Coding Validation implementations, including reviewing test claims, and internal go-live support.
• Act as a support liaison for appeals management process.

Quality:

• Support CPE Clinical Services quality assurance processes including pre and post release testing and other areas of need as identified.
• Assist the Clinical Content Teams with validation and review of client payment policies.
• Maintain Client Information Workbooks with updated information as needed to maintain accuracy in CV review.
• Provide support during user acceptance testing in Nucleus.

Education (required)

• Associate or Bachelor’s degree in Nursing (active/unrestricted license)

License & Certification-

• Registered Nursing license (RN) – active and unrestricted in state of residence.
• Professional coder certification (CPC, CPC-H, CPC-P, or CCS-P), RHIT or RHIA certification required. 

Experience

• 2+ years of clinical experience as a Registered Nurse.
• 1+ years of experience in Coding Validation.
• 1+ years of experience in coding including professional and outpatient facilities.
• 1+ years of experience in claims adjudication, medical/payment policy, or utilization review working for a managed care or healthcare insurance company, or related experience.
• 1+ years of experience in customer service or client management with a strong focus on healthcare setting.

Skills and Other Requirements:

• Ability to analyze complex data and synthesize it for customer and internal consumption.
• Strong research capabilities and knowledge of CMS guidelines and other regulatory compliance guidelines and mandates, and medical payment policy.
• Proficient with Microsoft Office Suite (Word, Excel, Power Point).
• Working knowledge of Cotiviti systems preferred.
• Demonstrates basic working knowledge of the following applications within 90 days of hire:
  • Nucleus, JIRA, Mantis, Microstrategy, Tableau
• Knowledge of medical terminology.
• Detail oriented.
• Ability to handle multiple tasks, prioritize and meet deadlines.
• Effective analytic and problem-solving skills.
• Professional with ability to properly handle confidential information.
• Ability to work well independently and a track record of successful outcomes within a collaborative team environment.
• Ability to work in a fast-paced environment, effectively organize, prioritize and meet deadlines.
• Strong written and verbal communication and interpersonal skills.
• Ability to work with remote cross-functional product teams.
• Computer and technology literate.
• 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 may be required where necessary for major deliverables/deadlines (not consistent).
• Travel requirement up to 10%

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.
• No adverse environmental conditions expected.

Base compensation ranges from $75,000 to $100,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. 

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: 3/14/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 5/14/2025, 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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