Lead Genetic Testing and Laboratory SME

COTIVITI, INC.

SOUTH JORDAN, UT

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JOB DETAILS

SKILLS

Artificial Intelligence (AI), Billing, Centers for Medicare and Medicaid Services (CMS), Channel Strategies, Clinical Study Publications, Cross-Functional, Current Procedural Terminology (CPT), Customer Acquisition, Customer Relations, Customer Satisfaction, Customer Support/Service, Data Mining, Establish Priorities, Genetics, Genomics, Healthcare Common Procedure Coding System (HCPCS), Laboratory Techniques, Laboratory Testing, Medical Records, Metrics, Next Generation Sequencing (NGS), Policy Development, Provider Abrasion, Risk, Sales Presentation, Technical Support, Test Lab, Trend Analysis

LOCATION

SOUTH JORDAN, UT

POSTED

1 day ago

Lead Genetic Testing and Laboratory SME Job Locations US-Remote ID 2026-19380 Category Clinical Position Type Full-Time Overview The Genetic Testing and Laboratory SME serves as the clinical and technical authority supporting the development, validation, and client presentation of payment integrity rules related to genetic testing and laboratory services. This role partners with Content Solutions Analysts (CST) to translate complex genomic and laboratory concepts into scalable, defensible rule logic across prepay and postpay (where appropriate) environments. This role is a key enabler of Cotiviti's genetic testing and laboratory payment integrity strategy, responsible for unlocking scalable prepay rule development and supporting measurable savings outcomes in a highly complex and rapidly evolving domain. Responsibilities Clinical and Technical Subject Matter Expertise Provide deep expertise in molecular diagnostics (germline and somatic), next-generation sequencing (NGS) and multigene panels, and laboratory billing practices (CPT/HCPCS, PLA codes, stacking). Interpret and operationalize guidance from Centers for Medicare and Medicaid Services (CMS), the American Medical Association (AMA), and specialty societies (e.g., NCCN, ACMG) to inform rule logic and defensibility. Identify and communicate emerging trends in overutilization, miscoding, unbundling, and panel misuse across genetic testing and laboratory services. Rule Development and Enablement (Core Function) Act as the primary clinical partner to CST analysts to translate clinical intent into prepay-editable rule logic, define inclusion/exclusion criteria and trigger logic, and ensure rules are feasible without medical record review where possible. Lead or co-lead development of Coding Validation (CV) edits, and postpay data-mining concepts across laboratory and genetic testing. Review and approve rule specifications for clinical validity, policy defensibility, and provider abrasion risk. Drive prioritization of prepay-feasible logic, clearly distinguishing between concepts requiring medical record review and those that can be operationalized at scale. Policy and Reference Development Develop structured references where formal policy is limited (e.g., Coding Insights and Claims Insights) using billing-behavior and utilization-pattern logic. Bridge gaps between published policy and real-world laboratory/genetic billing practices to support consistent implementation and client-facing explanation. Client Engagement and Presentation Present rule logic and strategy to payer clients; translate complex genetic testing concepts into clear clinical narratives and financial impact/savings opportunity. Support client discussions on defensibility, prepay vs. postpay strategy, and provider abrasion mitigation. Example Deliverables Genetic testing and laboratory rule specifications. Clinical rationale documentation for rule decks and client presentations. Identification of high-value savings opportunities in genetic testing utilization. Contributions to roadmap initiatives (e.g., lab expansion, AI-generated concepts). Success Metrics Number of genetic/lab rules developed and deployed. Savings generated (total and per rule). Percentage of rules operationalized in prepay. Reduction in false positives / provider abrasion indicators. Client adoption and satisfaction. Cross-Functional Collaboration Serve as the final clinical authority on genetic testing and laboratory rule intent, supporting alignment across CST, Maintenance, and Product. Partner with Content Solutions (rule development), Maintenance/Policy Owners (validation and production), Product... For fu l info follow application link. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

About the Company

COTIVITI, INC.

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