Concept Development Analyst (Automated Concepts)

Cotiviti•Remote,

1d•Remote

About The Position

In the role of Concept Development Analyst (CDA) within our CCV business unit, you will support the enhancement and ongoing optimization of claim selection processes and tools, including AI-enabled methodologies. This role is primarily focused on applying deep clinical, coding, analytical, and reimbursement expertise to strengthen and operationalize existing selection strategies. Leveraging your knowledge of inpatient billing, you will contribute to improvements in proprietary claim selection tools that drive accurate, compliant, and scalable payment integrity outcomes. Your understanding of healthcare payment methodologies, coding behavior, and reimbursement rules is essential to ensuring selection methodologies align with real-world audit and billing practices. As the coding subject matter expert, you will partner closely with AI data scientists, analytics teams, and senior leaders, providing coding guidance, analytical insights, and validation to inform model development, tuning, and output evaluation. While this role may occasionally support the identification of new audit opportunities, its primary focus is on enabling model performance and selection effectiveness, rather than leading independent concept development. This position supports analysis of selection outputs, taking meaningful action based on audit performance trends, and investigating identified variances. The role is well suited for individuals who excel as technical collaborators, prefer working as trusted SMEs in the development of AI-powered tools, and are motivated by improving claim selection accuracy through data-driven tools and processes. Cotiviti is seeking an experienced Concept Development Analyst (CDA) to support and advance automated, data‑driven audit strategies across Medicare and Government programs. This role is ideal for a billing, coding, and reimbursement expert who thrives in analytical environments and wants to apply their expertise to work closely with AI data scientists and analytics teams to inform and tune model logic and feature design to ensure selection methodologies align with real-world audit and billing practices. In this role, you will help design, validate, and optimize automated audit concepts that identify claim selections targeting improper payments using claims data only. Your work directly influences scalable, compliant payment‑integrity outcomes across inpatient, outpatient, and professional services. As a CDA, your understanding of healthcare payment methodologies, Medicare regulatory policy, coding standards and behavior, and reimbursement rules is essential to validation of automated selection methodologies and outputs ensuring compliance with billing and coding accuracy, reimbursement appropriateness, and regulatory alignment. As a trusted subject matter expert, you will leverage new technologies that target emerging coding and billing risks suitable for automated detection, advise senior leaders and audit operations, analyze performance trends, false positives, edge cases, and translate findings into actionable improvements.

Requirements

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.).
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.

Nice To Haves

AAPC or AHIMA coding certification preferred.
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.

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 implement 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 recovery, 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.
Complete all responsibilities as outlined in the annual performance review and/or goal setting.
Complete all special projects and other duties as assigned.
Must be able to perform duties with or without reasonable accommodation. This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.