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Concept Developer, Concept Optimization

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POST DATE 8/10/2016
END DATE 12/1/2016

Cotiviti USA, LLC Blue Bell, PA

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



The Concept Developer is responsible for developing new and existing audit concepts to generate high quality and recoverable claims for the benefit of Cotiviti Healthcare and our clients. Works within a shared service organization and interacts with account teams to supplement and assist local concept development efforts.

Key Responsibilities

* Generates and Develops New Audit Concepts. Utilizes healthcare experience to identify areas of vulnerabilities for improper payments that includes analyzing, identifying and defining issues, developing criteria and reviewing qualifying claims to ensure accurate edit parameters are applied.

* Provides Research and Support for Local Accounts. Works with local account teams to supplement their research and development effort. This includes reviewing authoritative documents to identify potential opportunities for improper payments, work with local teams to create appropriate edit parameters and testing report criteria for accuracy.

* Optimizes Existing Concept. Works with the concept optimization team to identify areas of opportunity to refine existing report criteria with the goal of improving efficiency and increasing ID Rate.

* Develops Training Material. Works with training and development team to product training documentation for concepts. Provides subject matter expertise to auditors and/or trainers on how to audit concepts and reports.

* Maintains Concept Library. Ensures that concept library is maintained and updated as required. Reviews concepts for continued accuracy according to an established review process. Ensures that up to date coding modifications are made to reports and deployed across the recovery audit division.



* Bachelor s degree required; Master s preferred

* Minimum of 3-5 years of related, claim auditing/payment integrity experience and process mapping experience.

* Broad knowledge of healthcare claims process across multiple provider types and disciplines.

* Prior experience developing edit parameters .

* Two years coding and auditing experience including inpatient and outpatient coding skills as well as ambulatory surgery, APC, emergency room, evaluation and management, auditing, report-writing expertise, required

* Strong knowledge of Microsoft Access

* Extensive knowledge of Medicare payment policies and guidelines. Experience applying Medicare LCD and NCD provision to claims to ensure compliance with all conditions of coverage and payment.

* 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.