Clinical Consultant I
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Job Description
Clinical Consultant supporting Cotiviti’s healthcare clients with Coding Validation, claims policy review, and quality testing. Advising teams throughout implementations, go-live, appeals, and operations.
Responsibilities:
- Support Clinical Services teams in validating quality and process consistency on the CPE editing engine
- Provide Coding Validation subject matter expertise to clients and internal stakeholders throughout planning, implementation, go-live, transition to operations, and contract duration
- Act as liaison for clinical information between internal partners and external customers
- Facilitate client understanding of Coding Validation policies and concepts
- Respond to client inquiries in compliance with policies and procedures
- Review and analyze Coding Validation client inquiries and Change Requests
- Assess impacts of decisions on affected policies and communicate with clients to clarify information
- Provide resources for provider abrasion issues and Coding Validation quality issues
- Explain Coding Validation coding concepts in writing and verbally
- Communicate quality review results and revisions to clients
- Develop action plans with the Quality Team to mitigate future issues
- Collaborate with Client Teams to develop and maintain client relationships
- Provide client-based input on edit configuration changes, rule updates, and new editing development
- Assist Clinical Content Teams with client-perspective feedback on trends and new rules
- Work with Quality, Training, and Operations Teams on review guideline updates, client-specific review changes, and client issues
- Support Coding Validation implementations, including reviewing test claims and internal go-live support
- Act as support liaison for the appeals management process
- Support CPE Clinical Services quality assurance, including pre- and post-release testing
- Assist with validation and review of client payment policies
- Maintain Client Information Workbooks
- Provide support during user acceptance testing in Nucleus
Requirements:
- Associate or Bachelor’s degree in Nursing
- Active and unrestricted Registered Nursing license (RN) in state of residence
- Professional coder certification (CPC, CPC-H, CPC-P, or CCS-P), RHIT, or RHIA certification required
- 2+ years of clinical experience as a Registered Nurse
- 1+ years of experience in Coding Validation
- 1+ years of experience in coding including professional and outpatient facilities
- 1+ years of experience in claims adjudication, medical/payment policy, or utilization review working for a managed care or healthcare insurance company, or related experience
- 1+ years of experience in customer service or client management with a strong focus on healthcare setting
- Ability to analyze complex data and synthesize it for customer and internal consumption
- Strong research capabilities and knowledge of CMS guidelines, regulatory compliance guidelines and mandates, and medical payment policy
- Proficient with Microsoft Office Suite (Word, Excel, PowerPoint)
- Working knowledge of Cotiviti systems preferred
- Demonstrates basic working knowledge of Nucleus, JIRA, Mantis, MicroStrategy, and Tableau within 90 days of hire
- Knowledge of medical terminology
- Effective analytic and problem-solving skills
- Ability to handle multiple tasks, prioritize, and meet deadlines
- Ability to properly handle confidential information
- Ability to work independently and collaboratively in a fast-paced environment
- Strong written and verbal communication and interpersonal skills
- Ability to work with remote cross-functional product teams
- Computer and technology literacy
- Flexibility to participate in an international organization’s work processes and global-time-zone conference calls
- After-hours and/or weekend work may be required for major deliverables/deadlines
- Travel requirement up to 10%
- Ability to provide a dedicated, secure work area
- Ability to provide high-speed internet access/connectivity and office setup and maintenance
- Ability to sit and use a computer keyboard for extended periods
- Must be located in the continental US
Benefits:
- Medical insurance
- Dental insurance
- Vision insurance
- Disability insurance
- Life insurance coverage
- 401(k) savings plan
- Paid family leave
- 9 paid holidays per year
- 17–27 days of Paid Time Off (PTO) per year, depending on level and length of service
- Remote work arrangement
- Dedicated, secure work area and high-speed internet/office setup provided by the worker
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