Concept Development Analyst - Readmissions

Overview

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.

Responsibilities

• 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. Required
• Complete all special projects and other duties as assigned. Required

Qualifications

• Minimum of 5 years of experience in medical billing, inpatient and outpatient coding, auditing or CDI required.
• Mastery of Inpatient Readmission payment policies and reimbursement related to commercial payers.
• Bachelor’s or graduate degree in nursing preferred; Health Information Management, Health Care Administration, or equivalent related health field additionally will be considered.
• AAPC or AHIMA coding certification preferred.
• 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, 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

Working Conditions and Physical Requirements:

• The role may require occasional travel for onsite training, typically limited to the duration of the initial training week.
• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Communicating with others to exchange information.
• Repeating motions that may include the wrists, hands and/or fingers.
• Assessing the accuracy, neatness and thoroughness of the work assigned.
• No adverse environmental conditions expected.
• Must be able to provide a dedicated, secure work area.
• Remote work with flexible schedule offered, must be able to accommodate EST time zone for scheduled daily operations.

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

Base compensation ranges from $88,000 to $110,000. 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.