Clinical Consultant I

Cotiviti•Remote,

2d•$80,000 - $95,000•Remote

About The Position

The Clinical Consultant supports Clinical Services teams in the validation of quality and process consistency on the CPE editing engine. This role provides 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. The consultant will clearly understand and articulate CV concepts and policies, collaborate with internal teams to provide meaningful input on CV processes, improvements, and support to maximize value and service for clients. Additionally, they will support internal teams with the preparation of new policy presentations and the appeals management process, as well as support the validation of quality and process consistency including customization requests, payment policies, pre and post testing, and UAT testing.

Requirements

Associate or Bachelor’s degree in Nursing (active/unrestricted license).
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.
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.
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).
Demonstrates basic working knowledge of the following applications within 90 days of hire: Nucleus, JIRA, Mantis, MicroStrategy, Tableau.
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.
Repeating motions that may include the wrists, hands, and/or fingers.
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.

Nice To Haves

Working knowledge of Cotiviti systems preferred.

Responsibilities

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.
Provide support and resources to clients for provider abrasion issues.
Review and provide written and/or verbal explanation of CV coding concepts.
Serve as a resource to clients for CV related quality issues.
Appropriately and effectively communicate quality review results and revisions (if applicable) to clients.
Provide action plans to mitigate future issues as needed with the Quality Team in close internal collaboration.
Proactively offer the 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.
Assist 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 the appeals management process.
Support CPE Clinical Services quality assurance processes including pre and post release testing and other areas of need as identified.
Assist 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.
Provide support during user acceptance testing in Nucleus.