Policy Design Specialist I

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

📋 Description

• Develop and modify new policies as well as update existing ones for clients to ensure alignment with industry standards and client expectations.

• Create and design policies requested by clients from the ground up, translating client expectations into Cotiviti guidelines for proper configuration.

• Implement project requests, design work orders, and closely monitor queues to guarantee all requests are fulfilled by the target completion date.

• Manage multiple priorities and oversee project deliverables for two or more healthcare clients.

• Offer proactive support on additional client accounts as necessary.

• Deliver exceptional customer service by documenting and keeping informed about all client sensitivities and configuration requirements.

• Investigate instances where configuration updates conflict with client customizations or requirements.

• Achieve daily and monthly production and quality objectives, maintaining a high level of accuracy in all tasks; ensure that the capture and completion of assigned projects are audited, making corrections as needed.

• Conduct regular quality checks to verify accuracy for all client policies by analyzing quality reports and troubleshooting results, identifying root causes and resolving issues promptly.

• Fulfill Peer Review duties by providing feedback to colleagues to assist in meeting departmental quality objectives.

• Accept peer feedback, identify trends, and propose clear solutions to reduce error rates.

• Address testing issues and conflicts related to policy configuration updates and overlaps.

• Analyze pre- and post-client claim data to ensure appropriate claim editing.

• Participate in client presentations by offering configuration expertise and documenting client decisions.

• Coordinate and manage activities following client presentations.

• Maintain thorough and current knowledge of internal applications, actively participating in all training and software release meetings.

• Communicate effectively and promptly with upstream functional areas to resolve issues.

⛳️ Requirements

• Bachelor’s Degree preferred or equivalent professional experience.

• Coding or HIM credential preferred (e.g., RHIA, CPC).

• At least 1 year of experience or understanding of medical terminology, anatomy, and physiology.

• Experience with health plan payment policies or internal company payment policies.

• A minimum of 2 years of experience in claim payment/adjudication, medical payment policy, hospital administration, or multispecialty exposure to professional and facility claims (or equivalent Cotiviti experience).

• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint).

• Experience with SQL is preferred.

• Ability to thrive in a team environment or work independently while performing well under pressure.

• Strong analytical and problem-solving abilities.

• Excellent verbal and written communication skills.

🏝️ 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 role and length of service with Cotiviti.