Concept Development Analyst

📋 Description

• Act as a coding and billing expert, providing clinical, coding, and reimbursement insights to support AI and analytics teams in shaping model logic, features, and outcomes.

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

• Aid in the tuning of model and selection logic by analyzing output trends, false positives, edge cases, and variances in key metrics.

• Recognize data quality issues, coding intricacies, or reimbursement factors that could affect selection performance and model outcomes.

• Work with stakeholders to align selection methodologies with operational workflows and real-world auditing processes.

• Lead the investigation, creation, and implementation of innovative concepts in various healthcare provider environments, leveraging comprehensive knowledge of healthcare billing, coding practices, clinical insights, and regulatory standards.

• Assist in exploring, improving, and executing audit concepts across healthcare settings using clinical, coding, and regulatory expertise.

• Identify and pursue opportunities for the development of coding and billing logic.

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

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

• Collaborate with engineering, analytics, audit teams, client management, and senior concept development members to align efforts and achieve results.

• If necessary, educate and train Audit Operations leaders and Medical Directors on identified audit opportunities.

• Effectively communicate findings with senior team members and managers.

• Exhibit proficiency in Medicare reimbursement models, coding and billing guidelines, and relevant industry standards.

• Monitor and adjust concept criteria and logic to incorporate any changes in legislation, coding rules, and policies.

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

• Review all concepts before and after client approval.

• Develop and maintain validation procedures for concepts, including regular assessments of all concepts, monitoring their performance, and reviewing relevant documentation.

• Utilize both internal and external tools, including AI-driven platforms, to assess, document, and validate new ideas, claims, and concept effectiveness.

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

• Apply a curious, analytical approach to assess imperfect or evolving data, translating insights into actionable recommendations that strengthen selection logic and audit concepts.

• Investigate and test new methodologies, tools, and technologies (including suitable AI-driven solutions) to improve concept performance and efficiency.

• Maintain a strong focus on outcomes and business impact, ensuring that concept development aligns with measurable results.

• Fulfill all responsibilities outlined in the annual performance review and/or goal setting.

• Complete special projects and other tasks as assigned, with the ability to perform duties 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).

• Bachelor’s or graduate degree is required.

• Proficiency in at least one area with a willingness to learn additional areas as necessary: Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Emergency Room, Behavioral Health.

• Required proficiency in Microsoft Excel, including the ability to navigate pivot tables and create basic formulas (e.g., VLOOKUP).

• Capability 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 is preferred.

• Proficiency with healthcare claim adjudication standards and procedures.

• Excellent verbal and written communication skills.

• Strong analytical and investigative abilities.

• Familiarity with HIPAA Privacy and Security Rules and CMS security requirements.

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

• Previous experience in auditing or consulting within either a provider or payer context is desirable.

• Experience utilizing AI-enabled tools (e.g., ChatGPT, Copilot, or similar) to analyze data, generate insights, improve workflows, or support analytical reasoning is preferred.

• Demonstrated curiosity, adaptability in the face of ambiguity, and a willingness to experiment with new analytical methods or tools to achieve significant 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.