The Medical Policy Specialist (MPS) is a key member of the Go To Market team. Along with the Client Engagement Leader, Client Medical Director (CMD), the MPS co-captains the team serving the Prospective Payment Management (PPM) client team at the health plan. The MPSs role is to serve as a coding and medical payment policy subject matter expert (SME), with the assistance of a CMD. The MPS is responsible for directing the Medical Policy Committee (joint committee with health plan MD, coding experts, and payment integrity). The MPS will develop a relationship with the client, review their data, select medical policy to present, serve as SME for clinical and coding expertise, and back-end support for Cotiviti’s and the client’s Medical Directors. The MPS will evolve as the trusted advisor for the Health Plan in terms of medical payment policy.

• Act as a knowledgebase expert regarding the Cotiviti Medical Policy library.
• Gain an understanding of each client’s unique lines of business, medical policy standards and system configuration strategy to inform optimization opportunities.
• Analyze client data and identify new medical policy opportunities for presentation including valuation and validation of editing.
• Examine and select specific claim examples to utilize in a presentation to the client to support the understanding of the new medical policy.
• Prepare various documents and presentation materials for use during internal payment policy committee meetings and/or client meetings.
• Review all documents and coordinate reviews with the CMD to evaluate and validate the editing and financial impact.
• Confidently perform client policy presentations to highlight the facts of each rule, the data that supports the policy recommendation, the impact to claims processing, and the associated value.
• Successfully advocate for the adoption of new medical policies by clients to optimize the value Cotiviti offers.
• Participate in client meetings as required as a medical policy subject matter expert.
• Coordinate with the internal client team to ensure that all requested follow-up items are delivered to the client.
• Inspire trust and credibility with clients.
• Communicate effectively across various organizational levels and members of the internal and external client teams.
• Assist in identifying opportunities for other Cotiviti product solutions.
• Complete all responsibilities as outlined in the annual performance review and/or goal setting.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and the requirements of the job change. 

• Bachelor’s Degree in a relevant field or equivalent.
• Professional coder certification required (CPC, CPC-A, CCA, CCS, or CCS-P), RHIT or RHIA certification a plus.
• Minimum of 7-10 years of work experience, preferably in sales, customer service or client management.
• Minimum of 5 years of experience in claim payment adjudication, medical payment/policy editing applying Medicare, Medicaid, ICD, CPT, HCPCS and other specialty society guidelines preferred.
• Health plan, managed care or health insurance experience preferred.
• Exceptional presentation, interpersonal, verbal and written communication skills.
• Superior organizational skills with the ability to work in a fast-faced environment, prioritize, and manage multiple competing deadlines with minimal direction.
• Strong problem-solving skills and an ability to think strategically.
• Ability to analyze complex data and synthesize it for general consumption.
• Demonstrated strategy and analytical thinking skills, with the ability to effectively communicate conclusions and recommendations to diverse audiences.
• Excellent computer skills in Microsoft Word, Excel, PowerPoint, and Outlook are a must.
• Willingness/availability to travel 10-20% is required.

Mental Requirements:

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of the work assigned.
• Ability to work with a high volume of transactions in a timely manner and meet deadlines.
• Must be able to perform daily functions with little or no direct supervision.

Working Conditions and Physical Requirements:

• This remote role can be located anywhere in the continental US.
• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Must be able to perform duties with or without reasonable accommodation.
• 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 are expected.

Base compensation ranges from $120,000 to $145,000 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: 9/8/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 11/8/2025, 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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