Concept Development Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as a coding and billing subject matter expert, providing clinical, coding, and reimbursement guidance to AI and analytics teams to inform model logic, features, and outcomes.

• Collaborate with data science and analytics teams to ensure clinical accuracy, coding integrity, and reimbursement appropriateness of AI-driven outputs.

• Assist in tuning model and selection logic by examining output trends, false positives, edge cases, and variances in key metrics.

• Recognize data quality limitations, coding nuances, or reimbursement factors that may affect selection performance and model outcomes.

• Work with stakeholders to ensure selection methodologies are in sync with operational workflows and real-world audit execution.

• Spearhead the exploration, generation, and implementation of innovative concepts across diverse healthcare provider settings, utilizing your extensive knowledge of healthcare billing and coding practices, clinical insights, and regulatory expertise.

• Aid in the exploration, refinement, and execution of audit concepts across healthcare providers by leveraging clinical, coding, and regulatory knowledge.

• Identify and pursue opportunities for developing coding and billing logic.

• Leverage healthcare and auditing experience to investigate, define, and resolve coding and/or billing issues.

• Establish audit procedures and selection methods for identified audit opportunities.

• Partner with engineering, analytics, audit teams, client management, and senior concept development members to achieve alignment and drive results.

• Provide education and training to Audit Operations leaders and Medical Directors on identified audit opportunities, when necessary.

• Effectively communicate results with senior team members and management.

• Exhibit expertise in Medicare reimbursement methodologies, coding and billing guidelines, and relevant industry standards.

• Monitor and revise concept criteria and logic to reflect changes in legislation, coding regulations, and policies.

• Nurture and implement innovative ideas, methods, and technological advancements to enhance audit production, communication, and client satisfaction.

• Review all concepts prior to and following client approval.

• Develop and maintain concept validation procedures, including scheduled validations for all concepts, monitoring concept performance, and reviewing related documentation.

• Utilize internal and external tools, including AI-enabled platforms, to assess, document, and validate new ideas, claims, and the effectiveness of concepts.

• Ensure that both new and existing concepts meet desired objectives regarding recoveries, collectability, and client acceptance.

• Apply a curious, analytical mindset to assess imperfect or evolving data and convert findings into actionable insights that enhance existing selection logic and audit concepts.

• Investigate and experiment with new techniques, tools, and technologies (including AI-driven solutions when suitable) to improve concept performance and efficiency.

• Maintain a strong focus on outcomes and business impact, aligning concept development initiatives with quantifiable results.

• Complete all responsibilities as outlined in the annual performance review and/or goal-setting process.

• Fulfill special projects and other assigned duties.

• Ability to perform responsibilities with or without reasonable accommodation.

⛳️ Requirements

• A minimum of 5 years of experience in data analytics, medical billing, inpatient and outpatient coding, auditing, or Clinical Documentation Improvement (CDI).

• A Bachelor’s or Graduate degree is required.

• Proficiency in at least one of the following, with a willingness to learn others as needed: Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Emergency Room, Behavioral Health.

• Required proficiency in Microsoft Excel, including navigating pivot tables and creating basic formulas (e.g., Vlookup).

• Capable of conducting basic data analyses independently.

• Comprehensive knowledge of healthcare coding systems and payment methodologies (CPT, HCPCS, ICD-10, HIPPS, and Revenue Codes, etc.).

• AAPC or AHIMA coding certification is preferred.

• Familiarity with healthcare claim adjudication standards and procedures.

• Excellent verbal and written communication skills.

• Strong analytical and investigative abilities.

• Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.

• Ability to work independently, prioritize tasks, and document progress effectively.

• Prior experience in auditing or consulting within either a provider or payer environment is desirable.

• Experience using AI-enabled tools (e.g., ChatGPT, Copilot, or similar) to explore data, generate insights, enhance workflows, or support analytical thinking is preferred.

• Demonstrated curiosity, comfort with ambiguity, and a willingness to experiment with new analytical methods or tools to achieve 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) annually, depending on specific level and length of service with Cotiviti.