Founded in 1979, Cotiviti provides analytics-driven payment and network solutions for the healthcare and retail industries, offering services that help payers,
Concept Development Analyst
Location
United States
Posted
67 days ago
Salary
$95K - $121K / year
Seniority
Senior
Job Description
Concept Development Analyst
Cotiviti
• 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. • Utilize healthcare and auditing experience to investigate, identify and define coding and/or billing issues. • Determine audit procedures, selection methods for identified audit opportunities. • Collaborate 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. • Communicate 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. • Foster 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 recoveries, collectability and client acceptance. • Apply a curious, analytical mindset to evaluate imperfect or evolving data and translate findings into actionable insights that strengthen existing selection logic and audit concepts. • Explore and experiment with new approaches, tools, and technologies (including AI-enabled solutions where appropriate) to enhance concept performance and efficiency. • Demonstrate 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.
Job Requirements
- 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.).
- AAPC or AHIMA coding certification preferred.
- 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.
- 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.
- Demonstrated curiosity, comfort working with ambiguity, and interest in experimenting with new analytical approaches or tools to drive meaningful outcomes.
Benefits
- medical, dental, vision, disability, and 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
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