Job Category: Medical , Finance, Customer Service

Location: United States (Home-based)

To be discussed.


The Client Policy Manager I manages client payment policies by ensuring client’s payment policy is accurate, up-to-date and complete. Ensuring execution of client specific requests and acting as theinternal and external client team liaison.

  • 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 ruleset, 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 participates in monthly/quarterly client policy meetings.
  • Reviews client’s payment policies for accuracy.
  • Completes reviews on a timely basis.
  • Clearly understands and articulates medical policies.
  • Presents the policies forreview and acceptance by the client.
  • Provides direction on client understanding of medical policies.
  • Adds value to Medical Policy andclient teams.Participates on Medical Policy and client teams.
  • Offers benefit of knowledge and experience proactively.
  • Communicates effectively with various members of the client team (internal as well as external).
  • Responsible for translating industry references into Cotiviti policy.
  • Reviews and identifies changes needed to client policies in order to maintain up-to-date and accurate medical payment policies.
  • 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.

What we’re looking for:

  • Experience in claim payment adjudication or medical payment policy.
  • Experience in CPT-4, ICD-9-CM and HCPCS coding.
  • Proficient in Microsoft Office Excel, Word and PowerPoint.
  • Working knowledge of Cotiviti systems.
  • Demonstrates basic working knowledge of less than three of the following applications: CDM (working PUR, creating adhoc presentation, capturing decisions, create NPP presentation), eLL, RMI, RMR, Business Objects Reporting and SQUISH.
  • Experience in customer service or client management with a strong focus on healthcare setting.
  • Strong Knowledge of CMS guidelines.
  • Health plans, Managed Care or Health Care insurance company experience.
  • Prior experience in developing medical payment policy edits.
  • Experience in claims adjudication or utilization review working for a managed care or healthcare insurance company.
  • Effective problem solving skills.
  • 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.
  • Must be able to sit and use a computer keyboard for extended periods of time.
  • After hours and/or weekend work may be required where necessary for major deliverables/deadlines (not consistent).
  • Travel requirement up to 25%.

How to Apply

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