Clinical Analyst & Coding Specialist (Remote)

Job Title: Clinical Analyst & Coding Specialist (Remote)

Location: Columbia SC

Duration: 12 Months

Job Description:

The IT Healthcare Consultant Business Analyst Advanced will support the medical code change requests by researching and making recommendations to policy and process owners and stakeholders for review and approval.

This position requires an individual with strong analytical skills and experience in:

• Managing multiple work efforts simultaneously
• Medical Coding
• Nursing
• Time management skills
• CPT/HCPCS and ICD-10 translation
• Ability to write and understand business and functional requirements.

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 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.

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.