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Clinical Content Specialist

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POST DATE 8/13/2016
END DATE 10/11/2016

Cotiviti USA, LLC Atlanta, GA

Atlanta, GA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree



The Clinical Content Specialist is a key member of the clinical operations and research team responsible for the research, quality assurance, and opportunity analysis associated with new medical policies. In addition, this position will be responsible for review and analysis of current medical policies and assisting in the research necessary to define additional logic and algorithms to expand the Cotiviti payment policy library. This position works in coordination with a US-based Research Medical Director.

Key Responsibilities

* Conducts thorough research and analysis for medical policy items

* Performs multi-faceted analytics for data and report analysis

* Responsible for translating industry references into Cotiviti policy

* Reviews and identifies changes to medical policies in order to maintain an accurate and current medical policy library

* Identifies new opportunities as appropriate from both clinical reference and analytical sources

* Analyzes research inquiries from a multitude of sources and applies solid clinical judgment to determine potential impact to medical policies

* Ability to determine if an update to existing policy logic or content is warranted based on changes to industry or Cotiviti reference data

* Performs QA of policy reviews, logic revisions, and research requests performed by others to ensure accuracy. In addition to QA, provides feedback to originator as needed.

* Educates client-facing MDs and Client Policy Managers (CPMs) on new changes and policy updates by actively participating in monthly meetings for client facing MDs and CPMs

* Manages interactions with our expert panel (consultant pool) on relevant clinical issues

* Ensures work is accurate, complete and finished in a timely manner including documentation of notable changes.

* Maintains current knowledgebase of industry and Cotiviti content, best practices, applications, procedures and policies


* Bachelors Degree (or higher) in Nursing (BSN) or Pharmacy (BSPharm or PharmD)

* Requires a valid RN or Pharmacist license

* Professional certification (RHIA, RHIT, CPC, CPC-H, CPC-P or CCS-P) preferred or willingness to attend coding courses sponsored by the Company

* Minimum of 5 years or experience in a clinical setting as a nurse or pharmacist

* Minimum of 3 years of experience in internet based research as it relates to codes (CPT, HCPCS, ICD, or NCD)

* Knowledge of coding or claims adjudication in one of the following areas preferred: Pharmacy, DME or Lab

* Knowledge of ICD-10 coding preferred

* Experience in a health plan, PBM, Medicare or State Medicaid with focus on reimbursement and/or claims processing preferred. Equivalent experience would be knowledge through a payer services organization working with one or more of the organizations noted above.

* Experience developing medical payment policy edits or algorithms (preferred)

* Maintains high degree of flexibility in performing research and analysis

* Responsive to learning new tools and analytical techniques

* Considers rule interactions and interconnectedness of current systems

* Capable of relating current system and operational responsibilities into new system and process design

* Exhibits accuracy and thoroughness

* Possess in depth knowledge of claims, claims adjudication, medical policy rules and edits

* Strong organizational and project management experience preferred.

* High attention to detail

* Strong analytical, critical thinking and problem solving skills

* Works with a sense of urgency

* Prior health plan operations experience helpful

* Prior understanding of client policy or client implementation services helpful

* Proficient with Microsoft Office Suite (Word, Excel, Power Point); Intermediate Excel

* Professional with ability to properly handle confidential information

* Ability to work well independently and in a team environment.

* Ability to handle multiple tasks, prioritize and meet deadlines.

* Ability to work within a matrix organization

* Excellent written and verbal communication skills

* Communicates with ease up and down the chain of leadership

* Must be able to sit and use a computer keyboard for extended periods of time

* Must be able to lift up to 20 lbs without assistance

* Occasional travel required (primarily related to training and quarterly meetings)

* Flexibility to travel outside the US based on business need is preferred

* Must have ability to positively handle/manage stress, such as high work volume and frequent change

* Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones.

* After hours and/or weekend work required where necessary for major deliverables/deadlines (not consistent)

* We are an Equal Opportunity Employer.

* Please view Equal Employment Opportunity Posters provided by OFCCP here.

* Cotiviti is an Equal Opportunity Employer. The Company provides equal employment opportunities to all applicants for employment without regard to gender, sexual orientation or preference, gender identity or expression, race, color, religion, national origin, ethnicity, ancestry, age, marital status, pregnancy, childbirth or related medical conditions, mental or physical disability, veteran status or any other characteristic protected by federal, state or local law, ordinance or regulation..

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin. We are also an equal opportunity employer of individuals with disabilities and protected veterans. Please view Equal Employment Opportunity Posters provided by OFCCP here.