Client Policy Manager I

Overview

The Client Policy Manager provides expert consultation on coding & clinical policy guidelines . This role works directly with our health plan clients and manages our clients payment policies and ensures they are accurate, up-to-date, and complete. This role is responsible for interpreting and assessing payment policy for clients and provides consultation and policy advice. This role works with a team of others: Medical Director, Client Managers, and Financial professional to deliver and implement clinical & coding guideline changes to their assigned clients.

Responsibilities

Policy Management

• Works with Medical Policy / Client team, aiding them in the evaluation and validation of editing, validation of savings as well as making selection for new policy opportunities including weighting of new rules. 
• Selects claims examples to utilize in presentation to the client & presents payment policy to clients for selection.
• Clearly understands and articulates medical policies. Presents policy changes for review and acceptance by the client. Provides direction on client understanding of medical policies.
• Reviews all documents and coordinates reviews with the Medical Directors. 
• Conducts research and analysis for medical policy items.
• Primarily responsible for the integrity of the client's medical policy set, including awareness of client-related Medical Policy Project Request, monthly review of Max Units, review of Health Plan rules, etc.
• Primary driver of the Periodic Update Analysis and leads monthly / quarterly client policy meetings.  
• Reviews client’s payment policies for accuracy and completes on a timely basis. 
• Builds Cotiviti value and credibility with clients by inspiring trust - delivers on commitments.
• Communicates effectively with various members of the client team (internal as well as external).
• Responsible for translating industry references into Cotiviti, Cotiviti policy.
• Performs multi-faceted analytics in all data and report analysis.
• Applies project management principles in initiating, creating and managing projects.
• Reviews and analyzes client inquiries for clarity of intent, applying decisions for affected policies, maintaining information and communicating effectively with the client.
• Provides expert consultation during the planning through operations phases, regarding coding regularity requirements and clinical policy guidelines.
• Function as a key member of the implementation team to collect, collate and articulate the client’s clinical and payment policies.
• Acts as the key liaison for the clinical information between internal partners and external customers during operations phases.
• Responds to client inquiries in a timely manner in compliance with policy and procedures.
• Works collaboratively with the Account Manager and Sales Executive to develop excellent client relationships.
• Provides clients with high quality and customized analysis of quarterly and ad hoc reports and recommends new reports that would be useful to their clients.
• Assists the Clinical Content Team with research of new trends and applications for new rules.
• Provides support to the sales team when presenting clinical information to prospective clients as needed.
• Provides client support during user acceptance testing.
• Completes all responsibilities as outlined on annual Performance Plan.
• Completes all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation

Qualifications

• Active professional license as a Registered Nurse (BSN preferred) or Bachelor’s Degree in Healthcare related field or equivalent relevant experience.
• CPC or equivalent certification required.
• Minimum of 3 years clinical coding experience, preferable in a payer setting.
• Possesses knowledge of healthcare claims payment policy and processing, specifically, CMS, Medicaid, ICD, CPT, HCPCS and other specialty society, etc.
• In depth knowledge of claims, claims adjudication, medical policy logic and recommendations.
• Proficiency in Microsoft Office suite...advanced skills in Excel preferred 
• Familiarity with claims payment and reimbursement methodologies.
• Ability to analyze complex data and synthesize it for customer and internal consumption.
• Ability to work well both independently and collaboratively, in a fast-paced and demanding environment.
• Effective at managing timelines and multiple projects.
• Effective presentation, verbal and written communication, and interpersonal skills.
• Ability to travel approximately up to 10% of the time (likely less).