Concept Development Analyst - DRG

About the role

The Concept Development Analyst (CDA) within our CCV business unit supports the enhancement and optimization of claim selection processes and tools, including AI-enabled methodologies. This role focuses on applying deep clinical, coding, analytical, and reimbursement expertise to strengthen and operationalize existing selection strategies.

Responsibilities

• 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.
• Utilizes healthcare and auditing experience to investigate, identify and define coding and/or billing issues.
• Determine audit procedures, selection methods for identified audit opportunities.
• Collaborates 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.
• Communicates 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.
• Fosters and implements 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.
• Applies a curious, analytical mindset to evaluate imperfect or evolving data and translate findings into actionable insights that strengthen existing selection logic and audit concepts.
• Explores and experiments with new approaches, tools, and technologies (including AI-enabled solutions where appropriate) to enhance concept performance and efficiency.
• Demonstrates a strong focus on outcomes and business impact, aligning concept development efforts with measurable results.

Qualifications

• 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.