Client Policy Manager

Role Overview

• manages client payment policies by ensuring client’s payment policy is accurate, up-to-date, and complete; executes client-specific requests with guidance from internal team
• acts as the internal and external client team liaison.
• Primarily responsible for the integrity of the client’s medical policy set, including awareness of all client-related Medical Policy project requests, monthly review of Max Units, review of Health Plan rules, etc.
• Primary driver of the Periodic Update analysis and industry updates.
• Review and identify changes needed to client policies in order to maintain up-to-date and accurate medical payment policies.
• Prepare payment policy documents for presentation to the client.
• Review all documents and coordinate reviews with Medical Directors and participate in client policy meetings.
• Conduct research and analysis for medical policy items with guidance from Cotiviti Client Medical Director and Content.
• Review client payment policies for accuracy, complete reviews on a timely basis, clearly understand and articulate medical policies, present the policies for consideration to Cotiviti Client Medical Director for review and acceptance by the client, provide direction on client understanding of medical policies.
• Add value to medical policy content, department, and client teams by participating and offering benefit of knowledge and experience proactively.
• Clearly understand, document and maintain client medical policy sensitivities and nuances in the Client Profile Workbook.
• Communicate effectively with various members of the client team (internal as well as external).
• Perform multi-faceted data and report analytics.
• Apply project management principles in initiating, creating, and managing projects.
• Review and analyze client inquiries for clarity of intent, apply decisions for affected policies, maintain information, and communicate effectively with the client.
• Completes all responsibilities as outlined on annual Performance Plan.
• Completes all special projects and other duties as assigned.

Requirements

• Active professional license as a Registered Nurse (BSN preferred) or Bachelor’s Degree in Healthcare related field or relative experience.
• Professional coder certification (CPC, CPC-H, CPC-P or CCS-P).
• Minimum of 3 years clinical coding experience, preferable in a payer setting.
• Strong knowledge of healthcare claims payment policy and processing, specifically, CMS, Medicaid, ICD, CPT, HCPCS and other specialty society, etc.
• Experience in claims adjudication or utilization review working for a managed care or healthcare insurance company.
• Familiarity with claims payment and reimbursement methodologies.
• Experience in customer service or client management with a strong focus on healthcare setting.
• Clearly understands and articulates medical policies.
• Strong Knowledge of CMS guidelines.
• Health plans, Managed Care or Health Care insurance company experience.
• Prior experience in developing medical payment policy edits.
• Proficiency in Microsoft Office suite.
• Demonstrated problem-solving skills.
• Professional with ability to properly handle confidential information.
• Ability to work well both independently and collaboratively, in a fast-paced and demanding environment.
• Ability to analyze data and synthesize it for customer and internal consumption.
• Effective verbal and written communication, and interpersonal skills.
• Effective at managing timelines and multiple projects with the ability to prioritize and meet deadlines.

Benefits

• medical, dental, vision, disability, and life insurance coverage
• 401(k) savings plans
• paid family leave
• 9 paid holidays per year
• 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti