Concept Development Analyst

🕒 May 19

🇺🇸 United States – Remote

💵 $95k - $121k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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Cotiviti

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

⚕️ Healthcare Insurance

💳 Fintech

🤖 Artificial Intelligence

Healthcare Insurance • Fintech • Artificial Intelligence

Cotiviti is a healthcare technology and analytics company that specializes in improving payment accuracy and performance through advanced data analytics solutions. They partner with health plans, government agencies, and healthcare providers to deliver insights that enhance quality and efficiency in care delivery. With solutions such as risk adjustment, payment policy management, and member engagement, Cotiviti aims to optimize financial and clinical outcomes for the healthcare ecosystem.

📋 Description

• 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.

🎯 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