Medical Policy Director

Cotiviti

1d • $120,000 - $145,000 • Remote

About The Position

The Medical Policy Director (MPD) is a key member of the Go To Market team. Along with the Client Engagement Leader, Client Medical Director (CMD), the MPD co-captains the team serving the Prospective Payment Management (PPM) client team at the health plan. The MPDs role is to serve as a coding and medical payment policy subject matter expert (SME), with the assistance of a CMD. The MPD is responsible for directing the Medical Policy Committee (joint committee with health plan MD, coding experts, and payment integrity). The MPD will develop a relationship with the client, review their data, select medical policy to present, serve as SME for clinical and coding expertise, and back-end support for Cotiviti’s and the client’s Medical Directors. The MPD will evolve as the trusted advisor for the Health Plan in terms of medical payment policy.

Requirements

• Bachelor’s Degree in a relevant field or equivalent.
• Professional coder certification required (CPC, CPC-A, CCA, CCS, or CCS-P), RHIT or RHIA certification a plus.
• Minimum of 7-10 years of work experience, preferably in sales, customer service or client management.
• Minimum of 5 years of experience in claim payment adjudication, medical payment/policy editing applying Medicare, Medicaid, ICD, CPT, HCPCS and other specialty society guidelines preferred.
• Health plan, managed care or health insurance experience preferred.
• Exceptional presentation, interpersonal, verbal and written communication skills.
• Superior organizational skills with the ability to work in a fast-faced environment, prioritize, and manage multiple competing deadlines with minimal direction.
• Strong problem-solving skills and an ability to think strategically.
• Ability to analyze complex data and synthesize it for general consumption.
• Demonstrated strategy and analytical thinking skills, with the ability to effectively communicate conclusions and recommendations to diverse audiences.
• Excellent computer skills in Microsoft Word, Excel, PowerPoint, and Outlook are a must.
• Willingness/availability to travel 10-20% is required.
• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of the work assigned.
• Ability to work with a high volume of transactions in a timely manner and meet deadlines.
• Must be able to perform daily functions with little or no direct supervision.
• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Must be able to perform duties with or without reasonable accommodation.
• 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.

Nice To Haves

• Professional coder certification required (CPC, CPC-A, CCA, CCS, or CCS-P), RHIT or RHIA certification a plus.
• Health plan, managed care or health insurance experience preferred.
• Minimum of 5 years of experience in claim payment adjudication, medical payment/policy editing applying Medicare, Medicaid, ICD, CPT, HCPCS and other specialty society guidelines preferred.

Responsibilities

• Act as a knowledgebase expert regarding the Cotiviti Medical Policy library.
• Gain an understanding of each client’s unique lines of business, medical policy standards and system configuration strategy to inform optimization opportunities.
• Analyze client data and identify new medical policy opportunities for presentation including valuation and validation of editing.
• Examine and select specific claim examples to utilize in a presentation to the client to support the understanding of the new medical policy.
• Prepare various documents and presentation materials for use during internal payment policy committee meetings and/or client meetings.
• Review all documents and coordinate reviews with the CMD to evaluate and validate the editing and financial impact.
• Confidently perform client policy presentations to highlight the facts of each rule, the data that supports the policy recommendation, the impact to claims processing, and the associated value.
• Successfully advocate for the adoption of new medical policies by clients to optimize the value Cotiviti offers.
• Participate in client meetings as required as a medical policy subject matter expert.
• Coordinate with the internal client team to ensure that all requested follow-up items are delivered to the client.
• Inspire trust and credibility with clients.
• Communicate effectively across various organizational levels and members of the internal and external client teams.
• Assist in identifying opportunities for other Cotiviti product solutions.
• 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.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level