Note: The job is a remote job and is open to candidates in USA. Cotiviti is a healthcare payment integrity company serving Medicare and Government programs. The Concept Development Analyst will apply clinical, coding, billing, reimbursement, and analytical expertise to design, validate, and optimize AI-enabled claim selection and automated audit concepts. The role partners with data science, analytics, engineering, audit, and leadership teams to improve model performance, coding accuracy, regulatory compliance, and payment integrity outcomes.
Responsibilities
- Serve as a coding and billing subject matter expert supporting AI and analytics teams by providing clinical, coding, and reimbursement guidance to inform model logic, features, and outcomes
- Partner with data science and analytics teams to validate AI-enabled outputs for clinical accuracy, coding integrity, and reimbursement appropriateness
- Support model and selection logic tuning by reviewing output trends, false positives, edge cases, and key metric specific variances
- Identify data quality limitations, coding nuances, or reimbursement considerations that may impact selection performance and model results
- Collaborate with stakeholders to ensure selection methodologies align with operational workflows and real-world audit execution
- Lead 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
- Support the exploration, enhancement, and execution of audit concepts across healthcare provider settings by applying clinical, coding, and regulatory expertise
- Identify and implement coding and billing logic development opportunities
- Utilizes healthcare and auditing experience to investigate, identify and define coding and/or billing issues
- Determine audit procedures, selection methods for identified audit opportunities
- Collaborates with engineering, analytics, audit teams, client management, and senior concept development team members to obtain alignment and drive results
- Educate and train Audit Operations leaders and Medical Directors on identified audit opportunities, if needed
- Communicates results effectively with senior team members and managers
- Demonstrate proficiency with Medicare reimbursement methodologies, coding and billing guidelines and applicable industry-based standards
- Monitor and update concept criteria and logic to reflect any changes in legislation, coding rules, and policies
- Fosters and implement new ideas, approaches, and technological improvements to support and enhance audit production, communication and client satisfaction
- Review all concepts before and after client approval
- Create and maintain concept validation procedures including scheduled validation of all concepts, monitoring concept performance, and reviewing associated documentation
- Utilize internal and external tools, including AI-enabled platforms, to evaluate, document, and validate new ideas, claims, and concept effectiveness
- Ensure new and existing concepts achieve desired goals in terms of recovery, collectability and client acceptance
- Applies a curious, analytical mindset to evaluate imperfect or evolving data and translate findings into actionable insights that strengthen existing selection logic and audit concepts
- Explores and experiments with new approaches, tools, and technologies (including AI-enabled solutions where appropriate) to enhance concept performance and efficiency
- Demonstrates a strong focus on outcomes and business impact, aligning concept development efforts with measurable results
- 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
Skills
- * Minimum of 5 years of experience in data analytics, medical billing, inpatient and outpatient coding, auditing, or CDI
- * Bachelor's or Graduate degree required
- * Proficiency in at least one and desire to learn others as needed: Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Emergency Room, Behavioral Health
- * Proficiency in Microsoft Excel required; e.g. navigate pivot tables and create basic formulas (e.g. Vlookup). Able to conduct basic data analyses independently
- * Mastery of healthcare coding systems and payment methodologies (CPT, HCPCS, ICD-10, HIPPS, and 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, prioritize tasks, and document progress
- * Demonstrated curiosity, comfort working with ambiguity, and interest in experimenting with new analytical approaches or tools to drive meaningful outcomes
- * Communicating with others to exchange information
- * Assessing the accuracy, neatness and thoroughness of the work assigned
- * 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
- * AAPC or AHIMA coding certification preferred
- * Prior auditing or consulting experience in either a provider or payer environment is desirable
- * Experience using AI-enabled tools (e.g., ChatGPT, Copilot, or similar, to explore data, generate insights, improve workflows, or support analytical thinking is preferred
Benefits
- Eligible for discretionary bonus consideration
- Medical insurance coverage
- Dental insurance coverage
- Vision insurance coverage
- Disability insurance coverage
- Life insurance coverage
- 401(k) savings plans
- Paid family leave
- 9 paid holidays per year
- 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti
Company Overview
Company H1B Sponsorship