Clinical Consultant I

Overview

The Clinical Consultant supports Clinical Services teams in the validation of quality and processes consistency on the CPE editing engine. They provide support and subject matter expertise on Coding Validation (CV) to both clients and internal stakeholders during the planning, implementation, go-live, transition to operational team, and through the duration of the contract.

Responsibilities

• Client facing Coding Validation support:
  • Act as a liaison for clinical information between internal partners and external customers.
  • Provide resources to facilitate client understanding of Coding Validation policies and concepts.
  • Respond to client inquiries in a timely manner in compliance with policy and procedures.
  • Review and analyze CV related client inquiries and Change Requests for clarity of intent, assessing impact of decisions for affected policies, and communicating effectively with the client to address questions or clarify information.
  • Support internal teams with preparation of new policy presentations and appeals management process.
  • Support validation of quality and process consistency including customization requests, payment policies, pre and post testing, and UAT testing.
• Add Value To Internal Teams:
  • Proactively offer benefit of CV knowledge and experience.
  • Work collaboratively with Client Teams to develop and maintain excellent client relationships.
  • Collaborate and provide input from a client-based perspective on changes in edit configuration, updates to existing rules, and development of new editing.
  • Aid the Clinical Content Team with feedback from a client perspective on new trends and application of new rules.
  • Work with Quality, Training, and Operations Teams as needed to facilitate any updates in CV review guidelines, effectively communicate changes in client specific review, and address other CV client issues in an accurate and timely manner.
  • Support resource for the Clinical Services team on Coding Validation implementations, including reviewing test claims, and internal go-live support.
  • Act as a support liaison for appeals management process.
• Quality Support:
  • CPE Clinical Services quality assurance processes including pre and post release testing and other areas of need as identified.
  • Aid the Clinical Content Teams with validation and review of client payment policies.
  • Maintain Client Information Workbooks with updated information as needed to maintain accuracy in CV review.
  • Support during user acceptance testing in Nucleus.

Qualifications

• Education (required): Associate or Bachelors degree in Nursing (active/unrestricted license).
• Licenses & Certifications: Registered Nursing license (RN) active and unrestricted in state of residence. Professional coder certification (CPC, CPC-H, CPC-P, or CCS-P), RHIT or RHIA certification required.
• Experience: 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.
• Skills & Other Requirements: Ability to analyze complex data and synthesize it for customer and internal consumption. Strong research capabilities and knowledge of CMS guidelines and other regulatory compliance guidelines and mandates, and medical payment policy. Proficient with Microsoft Office Suite (Word, Excel, Power Point). Working knowledge of Cotiviti systems preferred. Knowledge of medical terminology. Detail oriented. Ability to handle multiple tasks, prioritize and meet deadlines. Effective analytic and problem-solving skills. Professional with ability to properly handle confidential information. Ability to work well independently and a track record of successful outcomes within a collaborative team environment. Ability to work in a fast-paced environment, effectively organize, prioritize and meet deadlines. Strong written and verbal communication and interpersonal skills. Ability to work with remote cross-functional product teams. Computer and technology literate. 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 may be required where necessary for major deliverables/deadlines (not consistent). Travel requirement up to 10%.
• Cognitive / Mental Requirements: Ability to analyze complex data and synthesize it for customer and internal consumption. Detail oriented. Effective analytic and problem-solving skills. Professional with ability to properly handle confidential information. Ability to work well independently and a track record of successful outcomes within a collaborative team environment. Ability to work in a fast-paced environment, effectively organize, handle multiple tasks, prioritize and meet deadlines. Ability to work with remote cross-functional product teams. Must have ability to positively handle/manage stress, such as high work volume and frequent change.
• Physical Requirements & Working Conditions: This remote role can be located anywhere in the continental US. Repeating motions that may include the wrists, hands, and/or fingers. Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones. Must be able to provide a dedicated, secure work area. Must be able to provide high-speed internet access/connectivity and office setup and maintenance. Must be able to sit and use a computer keyboard for extended periods of time. No adverse environmental conditions expected.

Pay & Benefits

Base compensation ranges from $80,000 to $95,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.