Business Analyst - Clinical Analyst & Coding Specialist

Job Summary:

• 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.
• The position will also participate as a project team member, as assigned, for related process improvements, Medicaid Management Information System (MMIS) enhancements and provide subject matter expertise for a future MMIS replacement.
• Candidates who enjoy working on complex, change-oriented projects with motivated team members will find this position attractive.

Skills and Experience:

• 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 candidate must have strong collaboration and relationship building skills.
• Experience in healthcare insurance

Job Responsibilities:

• 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:

• 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.
• Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (AND
• 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; o r able to become certified within one year of employment.

Preferred:

• 5\+ years' experience in policy remediation.
• 5\+ years claims processing systems experience.
• 5\+ years Optum Encoder and/or other medical coding software programs