About this role
This role supports research, quality assurance, and opportunity analysis for new and existing medical policies, with a focus on pharmacy claims editing. The analyst translates industry references into Cotiviti policy business logic and supports rule-engine and grooming sessions with developers and architects.
Key Responsibilities
- Analyze claims payment and reimbursement methodologies and medical policy rules
- Provide coding, claims processing, and industry expertise to create pharmacy claims editing policy
- Write business logic for new rules and enhancements and translate industry references into Cotiviti policy
- Provide input to rule engine developers/system architects and guide developers during grooming sessions
- Perform multi-faceted analytics and mentor/train new staff
Technical Overview
The position works with claims editing policy creation, writing business logic for new rules and enhancements, and collaborating with ART teams and rule engine developers. It also performs analytics on claims/policy data and supports operational teams with the content solutions roadmap.
Ideal Candidate
The ideal candidate is a pharmacist (BSPharm or PharmD) with 3+ years of experience as a pharmacist/payer/pharmacy-related role and deep knowledge of claims payment and reimbursement methodologies. They have 5+ years of experience gathering rule requirements and developing rules/business logic for clinical or pharmacy claims editing policies, with strong analytics and clear communication.
Must-Have Skills
Pharmacist (BSPharm or PharmD)3 years in clinicalretail or working for a payer as a pharmacist or physician5 years previous experience in detailed rule requirement gatheringrule developmentand collaborating on software enhancementsStrong analyticalcritical thinking and problem-solving skillsProficiency in Microsoft Office SuiteEffective at managing timelines and multiple projects with high accuracy and attention to detailProvide codingclaims processing and industry expertise to help create clinical coding or pharmacy claims editing policyResponsible for writing business logic for new rules and enhancements by translating industry references into Cotiviti policyWork within the ARTspecifically providing guidance and input to TPO’s/developers during grooming sessions
Nice-to-Have Skills
RHIARHITCPCCPC-HCCS-PSAFeCPhTAfter hours and/or weekend work required where necessary for major del
Tools & Platforms
Microsoft Office Suite
Required Skills
pharmacistclaims paymentreimbursement methodologiesmedical policy rulespharmacy claims editing policycodingclaims processingrule requirement gatheringrule developmentrule enginebusiness logicCPTHCPCSICDNDCMicrosoft Office SuiteRHIARHITCPCCPC-HCCS-PSAFeCPhT
Hard Skills
Pharmacistclaims paymentreimbursement methodologiesmedical policy rulesclaims processingpharmacy claims editing policybusiness logicrule developmentcodingrule requirement gatheringrule engineclinical codingpharmacy claims editing policymulti-faceted analyticsdata report analysisMicrosoft Office SuiteCPTHCPCSICDNDCMBBSRHIARHITCPCCPC-HCCS-PCPhT
Soft Skills
analyze complex datasynthesize data for customer and internal consumptionwork independentlywork collaborativelymanage timelinesmanage multiple projectshigh accuracyattention to detailmentor and train new staffprovide input on peer workQA on peer workexcellent interpersonal skillsexcellent verbal and written communication skillsmanage record keepingwork in fast-paced and demanding environmentprovide guidance and input during grooming sessions
Certifications
Required
RHIARHITCPCCPC-HCCS-PSAFeCPhT
Keywords for Your Resume
Content Solutions Analyst II - RXContent Solutions Analyst II (RX)pharmacistBSPharmPharmDclaims paymentreimbursement methodologiesmedical policy rulesclaims payment and reimbursement methodologiespharmacy claims editing policycodingclaims processingrule requirement gatheringrule developmentrule enginebusiness logicCPTHCPCSICDNDCMicrosoft Office SuiteRHIARHITCPCCPC-HCCS-PSAFeCPhT
Deal Breakers
Must be a pharmacist (BSPharm or PharmD) or meet pharmacist education requirement, Must have 3+ years as a pharmacist or in a payer/clinical setting, Must have 5 years of rule requirement gathering and rule development collaborating on software enhancements, Must be proficient in Microsoft Office Suite
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