Policy Design Specialist I

Overview

The Policy Design Specialist role is responsible for managing health plan clients and executing monthly project requests. Perform policy configuration maintenance of current medical policies along with implementing new health plan medical policies per client request. Adhere to and remain in alignment with the most up to date healthcare industry medical coding guidelines. Perform data analysis to determine how to accurately apply coding updates and client requested customizations. Execute quality assurance checks to ensure appropriate claim editing recommendations are applied based on client request.

Responsibilities

• Implement new policies and update existing policies for clients to ensure the policy is editing in accordance with the industry and per the client’s expectation.
• Write and design client requested policies from scratch, translating client expectations into Cotiviti guidelines to ensure appropriate configuration.
• Execute projects requests, design work orders, and actively monitor queues to ensure all requests are completed by the desired completion date.
• Balance multiple priorities and manage projects deliverables for two or more healthcare clients. Proactively assist on other client accounts where needed.
• Provide the highest level of customer service by documenting and staying current regarding all client sensitivities and configuration needs. Investigate situations where configuration updates conflict with client customizations or needs.
• Meet daily and monthly production and quality targets; maintaining an exemplary level of accuracy in all work; ensuring that the capture and completion of assigned projects are audited and that corrections are made where needed.
• Perform regular quality checks to ensure accuracy for all a client’s policy set by analyzing quality reports and troubleshoot results, determining root cause(s) and promptly resolving.
• Perform Peer Review responsibilities by providing feedback to peers assisting in achieving department quality goals. Receive peer feedback, identifying any trends and proposing concise solutions to minimize error rate.
• Resolve testing issues and conflicts related to policy configuration updates and policy overlaps.
• Analyze pre and post client claim data to ensure appropriate claim editing.
• Participate in client presentations by providing configuration expertise and capturing client decisions. Coordinates and manages post-client presentation activities.
• Maintain detailed and up to date knowledge of internal applications, actively participating in all trainings and software release meetings.
• Communicate effectively and timely with upstream functional areas to resolve issues.

Qualifications

• Bachelor's Degree preferred or equivalent work experience.
• Coding or HIM credential preferred (RHIA, CPC, etc.).
• 1 or more years of experience / understanding of: medical terminology, anatomy and physiology.
• Health plan payment policy experience or internal company payment policy experience.
• 2 or more years of experience in claim payment/adjudication, medical payment policy, experience in hospital administration, or multispecialty experience and exposure to professional and facility claims (or equivalent Cotiviti experience).
• Proficient with Microsoft Office Suite (Word, Excel, Power Point).
• Experience with SQL preferred.
• Ability to work well in a team environment or independently and perform well under pressure.
• Strong analytical and problem-solving skills.
• Communicates with ease up and down the chain of leadership.
• Ability to handle multiple tasks, prioritize, and meet deadlines.
• Excellent verbal and written communication skills.

Job Demands:

• This is a work at home position (US only).
• Not currently, but long-term minimal travel may be required for this role.
• 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 required where necessary for major deliverables/deadlines (not consistent).
• Must have ability to positively handle/manage stress, such as high work volume and frequent change.

Mental Requirements:

• Effective time management skills and understanding of time sensitivity.
• Ability to manage multiple projects and tasks simultaneously, prioritizing as necessary.
• Clear and effective communication skills for conveying findings and insights to team members, management, and collaborating teams.

Working Conditions and Physical Requirements:

• Prolonged periods of sitting and extensive computer use, including typing and using a mouse.
• Ability to operate office equipment such as computers, keyboards, and headsets.
• Must be able to provide high-speed internet access / connectivity and office setup and maintenance.
• Must be able to provide a dedicated, secure work area.

Base compensation ranges from $23.00 to $25.00 per hour. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs.

Nonexempt employees are eligible to receive overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law.

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: 3/31/2026

Applications are assessed on a rolling basis. We anticipate that the application window will close on 05/31/26, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.