Overview:
As a Concept Development Analyst (CDA) within the Clinical Chart Validation team, you’ll spearhead the identification, creation, and implementation of inpatient claim selection rules focusing on the payment integrity of the billed DRG. Leveraging your industry experience and deep knowledge of inpatient coding practices, APR-DRG methodologies, and billing regulations, you’ll craft innovative strategies to enhance claim selection processes, contributing directly to payment integrity for our clients.
Your data analysis expertise, strong organizational skills, and comprehensive understanding of claim selection methods will be instrumental in innovating and optimizing proprietary tools that uphold the highest standards of payment accuracy. You’ll work closely with senior team members, playing a pivotal role in refining and executing methodologies that elevate our claim selection strategies focused on inpatient claims.
This position involves research, development, implementation, and maintenance of new audit opportunities, with a primary focus on DRG validation prior to the claim being paid. As a CDA, you’ll be responsible for monitoring query outputs, tracking audit performance outcomes, and investigating discrepancies or variances, ensuring consistent alignment with our team’s objectives and the evolving needs of the healthcare billing landscape.
We are seeking candidates with a proven track record of possessing strong analytical and research skills. The ideal candidate should demonstrate the ability to critically analyze information, think logically, and draw meaningful insights from data. Additionally, a keen attention to detail and the capacity to conduct thorough research to gather relevant information are paramount.
Candidate should be self-motivated and capable of working independently, demonstrating the ability to make sound decisions autonomously when necessary.

Responsibilities:

• Spearheads the analytical exploration, generation, and execution of unique selection rules focused within our inpatient claim audit scope.
• Create selection rules that are complementary of existing library, 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.
• DRG subject matter expert for the expansion of Prepay DRG validation, AI, and Natural Language Processing technology.
• Proficiency in Excel, including demonstrated experience with pivot tables, basic functions, simple formulas, and data filtering is required.
• Utilizes healthcare and auditing experience to investigate, identify and define coding and/or billing issues.
• Participates in strategic planning to develop methods for integrating new technology into existing tools.
• Collaborates with engineering, analytics, audit teams, client management, and senior concept development team members to complete routine tasks.
• Leads the education and training to the Auditor Training Team, Medical Directors, and audit leaders on new DRG 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 and scope.
• 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 implementation.
• 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 satisfaction.
• Complete all responsibilities as outlined on annual Performance Plan. Required.
• Complete all special projects and other duties as assigned. Required.
• Must be able to perform duties with or without reasonable accommodation. Required.

Qualifications:

• Minimum of 5 years of experience in inpatient coding or DRG validation auditing required.
• Mastery of APR-DRG methodology is required.
• Bachelor’s or graduate degree in Healthcare Informatics, Health Information Management, Health Care Administration, or equivalent related health field preferred.
• 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.
• Experience with other 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.
• 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.

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.
  Base compensation ranges from $95,000 to $120,000. 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.
  

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• Spearheads the analytical exploration, generation, and execution of unique selection rules focused within our inpatient claim audit scope.
• Create selection rules that are complementary of existing library, 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.
• DRG subject matter expert for the expansion of Prepay DRG validation, AI, and Natural Language Processing technology.
• Proficiency in Excel, including demonstrated experience with pivot tables, basic functions, simple formulas, and data filtering is required.
• Utilizes healthcare and auditing experience to investigate, identify and define coding and/or billing issues.
• Participates in strategic planning to develop methods for integrating new technology into existing tools.
• Collaborates with engineering, analytics, audit teams, client management, and senior concept development team members to complete routine tasks.
• Leads the education and training to the Auditor Training Team, Medical Directors, and audit leaders on new DRG 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 and scope.
• 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 implementation.
• 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 satisfaction.
• Complete all responsibilities as outlined on annual Performance Plan. Required.
• Complete all special projects and other duties as assigned. Required.
• Must be able to perform duties with or without reasonable accommodation. Required