Clinical Content Specialist

Administrative CLINI02412

  • Full-Time
  • Nationwide (Remote)

Job Details


Key Responsibilities

  • Conducts thorough research and analysis for medical policy items
  • Performs multi-faceted analytics for data and report analysis
  • Responsible for translating industry references into Cotiviti policy
  • Reviews and identifies changes to medical policies in order to maintain an accurate and current medical policy library
  • Identifies new opportunities as appropriate from both clinical reference and analytical sources
  • Analyzes research inquiries from a multitude of sources and applies solid clinical judgment to determine potential impact to medical policies
  • Ability to determine if an update to existing policy logic or content is warranted based on changes to industry or Cotiviti reference data
  • Performs QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy. In addition to QA, provides feedback to originator as needed.
  • Educates client-facing Medical Directors (MDs) and Client Policy Managers (CPMs) on new changes and policy updates by actively participating in monthly meetings for client facing MDs and CPMs
  • Manages interactions with our expert panel (consultant pool) on relevant clinical issues
  • Ensures work is accurate, complete and finished in a timely manner including documentation of notable changes.
  • Maintains current knowledge base of industry and Cotiviti content, best practices, applications, procedures and policies

Other Related Responsibilities

  • Drives and supports the vision and values of Cotiviti and abides by all company policies and procedures.
  • Improves and implements procedures as needed and/or assigned.
  • Consistently provides optimum service to all internal and external customers.
  • Consistently works to develop and maintain positive and professional relationships with all internal and external customers.
  • Other duties as assigned

Education / Certification Requirements

  • Bachelors Degree (or higher) in Nursing (BSN) or Pharmacy (BSPharm or PharmD); Offshore Medical Degrees (MBBS or higher)
  • Professional certification (RHIA, RHIT, CPC, CPC-H, CPC-P or CCS-P) preferred or willingness to attend coding courses sponsored by the Company

Knowledge & Experience

  • Minimum of 5 years or experience in a clinical setting as a nurse or pharmacist or physician
  • Minimum of 3 years of experience in internet-based research as it relates to codes (CPT, HCPCS, ICD, or NCD)
  • Knowledge of coding or claims adjudication in one of the following areas preferred: Pharmacy, DME or Lab
  • Knowledge of ICD-10 coding preferred
  • Experience in a health plan, PBM, Medicare or State Medicaid with focus on reimbursement and/or claims processing preferred. Equivalent experience would be knowledge through a payer services organization working with one or more of the organizations noted above.
  • Experience developing medical payment policy edits or algorithms (preferred)
  • Maintains high degree of flexibility in performing research and analysis
  • Responsive to learning new tools and analytical techniques
  • Considers rule interactions and interconnectedness of current systems
  • Capable of relating current system and operational responsibilities into new system and process design
  • Exhibits accuracy and thoroughness
  • Possess in-depth knowledge of claims, claims adjudication, medical policy rules and edits
  • Strong organizational and project management experience preferred.
  • High attention to detail
  • Strong analytical, critical thinking and problem-solving skills
  • Works with a sense of urgency
  • Proficient with Microsoft Office Suite (Word, Excel, PowerPoint); Intermediate Excel
  • Professional with ability to properly handle confidential information
  • Ability to work well independently and in a team environment.
  • Ability to handle multiple tasks, prioritize and meet deadlines.
  • Excellent written and verbal communication skills
  • Communicates with ease up and down the chain of leadership

Working Environment

  • This role can be located at one of our US offices or can work remotely in the continental US.
  • High-speed internet connection (wired) is required.
  • Must be able to sit and use a computer keyboard for extended periods of time
  • Occasional travel required (primarily related to training and quarterly meetings)
  • Flexibility to travel outside the US based on business need is preferred
  • Must have ability to positively handle/manage stress, such as high work volume and frequent change
  • 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)

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.