Job Description:

Description

The Policy Quality Auditor (PQA) role supports product development and product delivery. The overall goal of this role is to ensure the accuracy of Cotiviti's Medical Policy Library and Custom Rule sets. The PQA ensures rules are created and maintained accurately and efficiently in the Rules Maintenance Interface (RMI) based on established Process Guidelines and Policy Configuration Guidelines. This role serves as the final checkpoint in validating the accuracy of rule creation and Policy Configuration of Cotiviti's rule set prior to its release into the Production environment. The PQA works closely with Policy Design Specialists, Policy Configuration Analysts and Policy Integration Coordinators.

Responsibilities:

• Completes RMR Audits prior to the designated monthly departmental deadlines


• Audits integration and configuration RMRs relating to changes within RMI


• RMR instructions are verified and peered for accuracy against CDM presentations, client summaries, decision matrix, Medicaid conflict documents, client testing, etc., based on client request


• Reviews Work Order Audit reports on specified RMRs to identify unintended changes


• Validates PR intent and verifies it was captured correctly on the RMR


• During PR audit, performs review of switch entries of Integration, Customs and Library to Library PRs (CDM and RMI review)


• Actively monitors the HCPCS and ICD queues within Industry Update application


• Validates TTK information under the direction of integration for audit of individual client implementation which includes but not limited to: DME, D&B, Outpatient, ASC, Professional, E&M, Crossover, Ambulance.


• TTK audit is based on review of Payer stream set ups, latest decisions by rule report (approve with mods), client requested modifications, table configuration for the client (payer tables and config tables, right click menu options, etc.), mappings, and any other items as requested


• Thoroughly documents audit findings in iTrak for each requested peer review and audit


• Validates that table data elements were loaded correctly in RMI


• Validates that appropriate documentation is captured on the RMR


• Actively monitoring the Medical Policy and Auditing queues in the RMR database to ensure all requests are audited for the appropriate Release Month


• Point Release assistance when needed and promptly by reviewing Project Request, Research Request, Point Release Request, P1 Switch Request for accuracy


• Gathers return trends and submits to Sr. Operations Manager/Supervisor for review


• Complete all responsibilities as outlined on annual Performance Plan


• Complete all special projects and other duties as assigned

Requirements:

• Bachelor's Degree (or higher) preferred (or equivalent experience)


• Knowledge of CPT-4, ICD-9-CM, ICD-10 and HCPCS coding, and medical terminology


• 2-year Cotiviti experience


• Meticulous attention to details.


• Ability to make decisions autonomously


• Ability to learn and quickly absorb new material; understands the big picture and fills in knowledge gaps


• Adapts to new and changing situations with relative ease


• Innate intellectual curiosity


• Focused on providing a quality product to our clients


• Ability to receive and provide constructive criticism and respond in a positive and professional manner


• Excellent analytical skills with ability to think "outside of the box"


• Proficient with Microsoft Office Suite (Word, Excel, Power Point)


• Professional with ability to properly handle confidential information


• Ability to work well independently and in a team environment


• Ability to handle multiple tasks, prioritize and meet deadlines


• Excellent written and verbal communication skills


• Highly organized and able to manage and prioritize many tasks


• Able to expand beyond units to understand cross-departmental impact


• Works well with team and fosters a team spirit environment


• Must have ability to positively handle/manage stress, such as high work volume and frequent change


• Must be able to sit and use a computer keyboard for extended periods of time


• Flexibility to work after hours & weekends, as needed


• Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones