Location Columbia, SC Experience Level Senior Level (10+ years in healthcare insurance; 5+ years in medical coding) Role Overview This dual-functioning IT Healthcare Consultant and Business Analyst role supports medical code change requests by researching, analyzing, and delivering recommendations to policy owners and stakeholders. Acting as a Subject Matter Expert (SME), the successful candidate will facilitate process improvements and system enhancements, bridging the gap between clinical requirements and IT implementation. This role is highly suited for a credentialed Registered Nurse (RN) and Certified Medical Coder who thrives in complex, change-oriented project environments. Key Responsibilities Medical Coding & Reference Maintenance Manage and initiate annual and quarterly updates from CMS for all ICD-10 and CPT/HCPCS coding changes. Perform initial reviews of code modifications to determine the scope of operational and system changes. Prepare detailed listings of code changes for review and analysis by program and administrative staff. Serve as the primary Subject Matter Expert (SME) for medical coding methodologies and related healthcare policies. IT Collaboration & System Enhancements Participate as a core project team member for process improvements and enterprise claims system enhancements. Provide reference administration expertise for large-scale, future system replacement initiatives. Research and maintain business rules, technical requirements, and data models within central repositories. Collaborate continuously with IT developers and programmers to align clinical needs with system capabilities. Stakeholder Engagement & Clinical Support Facilitate and conduct meetings with cross-functional personnel, stakeholders, and process owners. Partner with team members to ensure process documentation and training materials are comprehensive and routinely updated. Serve as a clinical back-up to review patient records against established criteria to determine medical necessity. Required Qualifications Education: Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN). Licensure: Current, active, and unrestricted Registered Nurse (RN) license in the State of South Carolina. Certification: Active Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) credential. Certification: ICD-10 Proficiency demonstrated by exam (or the ability to become certified within one year of employment). 10+ years of experience in healthcare insurance, medical review, program integrity, or appeals. 5+ years of experience performing medical coding in a payer environment. 5+ years of experience working directly with IT developers and programmers in a payer environment. 3+ years of clinical experience in a healthcare setting. 5+ years of deep foundational knowledge in ICD/CPT/HCPCS translation, coding methodologies, anatomy, physiology, pharmacology, and medical terminology. Preferred Qualifications 5+ years of experience in policy remediation. 5+ years of experience working with healthcare claims processing systems. 5+ years of experience utilizing Optum Encoder and/or other prominent medical coding software programs. Proficiency with Microsoft Office suite and standard business tools. Core Skills & Attributes Strong clinical assessment and critical thinking capabilities. Ability to effectively translate complex clinical and coding rules into actionable IT requirements. Excellent verbal and written communication skills to engage and guide stakeholders at all levels. Proven capability to work collaboratively in a fast-paced, change-oriented team environment. Flexible work from home options available. #J-18808-Ljbffr
Clinical Systems Analyst • Columbia, SC, United States
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