Lead Genetic Testing and Laboratory SME

Overview

The Genetic Testing & 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 & 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 & 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 & 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 & 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 & 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 & production), Product (platform constraints and enhancements), and AI/analytics teams (concept generation and pattern detection). Actively shape and inform roadmap initiative related to genetic testing expansion, lab editing strategy, and AI-driven rule ideation. Complete all responsibilities as outlined in the annual performance review and/or goal setting. Complete all special projects and other duties as assigned. Must be able to perform duties with or without reasonable accommodation. This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.

Qualifications

Education Master’s degree in Genetic Counseling or related field. Certifications Board certification preferred (ABGC or equivalent). Experience 6-8+ years in genetic counseling, molecular diagnostics, and/or laboratory utilization management. Strong preference for experience in payer, lab benefit management, or advisory environments translating clinical guidance into operational or policy frameworks. Technical Skills Deep knowledge of CPT/HCPCS coding for lab/genetic testing, including NGS panel billing complexity and common billing patterns (e.g., stacking and unbundling). Knowledge of prior authorization and utilization management frameworks as applied to genetic testing and laboratory services. Ability to translate clinical nuance into structured, scalable rule logic for prepay and postpay payment integrity solutions. Core Competencies Clinical-to-technical translation and structured problem solving. Executive communication and client-facing presentation skills. Cross-functional influence and collaboration. Ability to balance savings opportunity with provider abrasion risk.

Nice to Have

Experience supporting client-facing engagements or presenting to payer stakeholders. Exposure to utilization analytics, claims data interpretation, or payment integrity programs. Cognitive/Mental Requirements: Ability to interpret complex clinical, genomic, and laboratory information and translate it into clear, defensible operational logic. Ability to critically evaluate coding and utilization patterns, identify outliers, and determine appropriate escalation and risk mitigation. Ability to read and apply payer policy, national guidance, and specialty society recommendations to decision-making and rule design. Ability to communicate complex topics to technical and non-technical audiences, including executive-level client stakeholders. Ability to manage multiple workstreams, maintain attention to detail, and produce high-quality outputs under deadlines. Ability to collaborate cross-functionally, incorporate feedback, and adapt to changing priorities and platform constraints. Working Conditions and Physical Requirements: Ability to remain in a stationary position (sitting and/or standing) for extended periods of time. Ability to operate a computer and other standard office productivity tools, including repetitive use of hands/fingers for typing and mouse use. Ability to communicate effectively with others to exchange accurate information (in person, by phone, and/or virtually). Ability to review clinical and coding documentation on screen for prolonged periods with appropriate breaks. Must be able to provide high-speed internet access / connectivity and office setup and maintenance. Must be able to provide a dedicated, secure work area. Work is performed in an office and/or home office environment with typical business hours; may require occasional travel for client meetings and occasional overtime based on business needs. Base compensation ranges from $110,000 to $140,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration. 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 our Careers page. Date of posting: 6/2/2026 Applications are assessed on a rolling basis. We anticipate that the application window will close on 8/2/2026, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected. #LI-JB1 #LI-Remote #senior Apply To This Job