Medical Policy Manager

Cotiviti; United States; Remote; USD 75,000 - 105,000; Full time

Job summary

A leading healthcare company seeks a Client Medical Policy Manager to ensure accuracy of client payment policies and serve as a liaison between internal teams and external clients. This role emphasizes client service, policy management, and requires an active RN license and coding expertise, offering competitive compensation and benefits.

Benefits

Medical, dental, vision insurance

401(k) savings plans

Paid family leave

Paid Time Off (17-27 days per year)

Qualifications

• 3 years clinical coding experience in a payer setting preferred.
• Strong knowledge of healthcare claims payment policy and processing.
• Experience in customer service or client management.

Responsibilities

• Manage client's medical policy set and ensure its accuracy.
• Conduct research and analysis for medical policy items.
• Prepare payment policy documents for client presentation.

Skills

Problem-solving skills

Effective communication

Data analysis

Education

Active professional license as a Registered Nurse

Bachelor's Degree in Healthcare or related field

Professional coder certification (CPC, CPC-H, CPC-P or CCS-P)

Tools

Microsoft Office suite

Job description

Overview

The Client Medical Policy Manager 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 and acts as the internal and external client team liaison.

Responsibilities

This position is client facing and requires a commitment to superior client service.

• Primarily responsible for the integrity of the client’s medical policy set, including awareness of allclient-related Medical Policy project requests, monthly review of Max Units, review of Health Planrules, etc.
• Primary driver of the Periodic Update analysis and industry updates. Review and identify changesneeded 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 coordinatereviews with Medical Directors and participate in client policy meetings.
• Conduct research and analysis for medical policy items with guidance from Cotiviti Client MedicalDirector and Content.
• Review client payment policies for accuracy, complete reviews on a timely basis, clearly understandand articulate medical policies, present the policies for consideration to Cotiviti Client Medical Directorfor 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 benefitof knowledge and experience proactively.
• Clearly understand, document and maintain client medical policy sensitivities and nuances in the ClientProfile 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, maintaininformation, and communicate effectively with the client.
• Completes all responsibilities as outlined on annual Performance Plan.
• Completes all special projects and other duties as assigned.

Qualifications

• Active professional license as a Registered Nurse (BSN preferred) or Bachelor’s Degree in Healthcarerelated 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 healthcareinsurance 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 companyexperience.
• 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.

Mental Requirements:

• Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones.
• Must be able to perform duties with or without reasonable accommodation.
• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of the work assigned.

Physical Requirements and Working Conditions:

• This remote role can be located anywhere in the continental US.
• Travel requirement up to 20%.
• Must be able to lift up to 20 lbs without assistance.
• After-hours and/or weekend work may be required where necessary for major deliverables /deadlines.
• Must be able to sit and use a computer keyboard for extended periods.
• Remaining in a stationary position, often standing or sitting for prolonged periods.
• 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.
• No adverse environmental conditions are expected.

Base compensation ranges from $75,000 to $105,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs.

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. For information about our benefits package, please refer to ourCareers page.

Date of posting: 6/24/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 8/24/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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