Business Analyst Clinical Analyst & Coding Specialist

Objectives to Be Fulfilled by Candidate:

The principal duties of this position are to assist with the CPT/HCPCS and ICD-10 code maintenance. As the IT Healthcare Consultant Business Analyst Advanced (Clinical Analyst and Coding Specialist):

Specific duties include but are not limited to:

• Initiates annual (and quarterly) updates from CMS of all ICD-10 CPT/HCPCS coding changes.
• Performs initial review of codes to determine scope of changes.
• Prepares listings of codes changes to Reference Administration staff and Medicaid Program staff for review and analysis.
• Conducts meetings with Agency personnel stakeholders and process owners.
• (Future) Participates in DASH (Replacement MMIS) project meetings as needed where reference administration expertise is required.
• Serves as an agency subject matter expert (SME) for medical coding methodologies Medicaid policy and related topics.
• Research business rules requirements and models to complete initial analysis and recommendations.
• Maintains business rules requirements and models in a repository.
• Collaborates with team to ensure process documentation is complete owner and stakeholder as needed training content is complete and routinely updated.
• May serve as a back-up to review patient records against established criteria to determine medical necessity.
• Other project-related duties.
• 5 years written and oral communications skills strong proficiency in English.
• Knowledge of Microsoft Office Suite

Required Skills (rank in order of Importance):

• 5 years in healthcare insurance; medical review program integrity or appeals.
• 5 years working with IT developers/programmers in a payor environment.
• 5 years Medical Coding in payer environment.
• 3 years clinical experience in a healthcare environment (strong clinical assessment and critical thinking skills.)
• 5 years knowledge of ICD/CPT/HCPCS translation and coding methodologies.
• 5 years knowledge of anatomy physiology pharmacology and medical terminology.

Preferred Skills (rank in order of Importance):

• 5 years experience in policy remediation.

• 5 years claims processing systems experience.
• 5 years Optum Encoder and/or other medical coding software programs

Required Education:

Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)

Required Certifications:

Must have current active and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.

Currently credentialed as CPC (Certified Professional Coder) or as CCS (Certified Coding Specialist). ICD-10 Proficiency demonstrated by exam; or able to become certified within one year of employment.