Business Analyst - Clinical Analyst & Coding Specialist - Contract - Remote

SUNSHINE ENTERPRISE USA LLC•Columbia, SC

20d•Remote

About The Position

We are seeking an experienced Business Analyst – Clinical Analyst & Coding Specialist to support Medicaid policy, coding analysis, claims processing, and MMIS initiatives for a large healthcare and government environment. This role will serve as a subject matter expert (SME) supporting medical coding compliance, coding updates, policy remediation, and Medicaid business process improvements. The ideal candidate will have strong experience in medical coding, healthcare insurance operations, Medicaid claims processing, and payer systems, along with a clinical background and the ability to collaborate with both technical and business teams. This role will also contribute to future MMIS modernization and replacement initiatives.

Requirements

5+ years of experience in healthcare insurance, medical review, program integrity, or appeals
5+ years of experience working with IT developers/programmers in a payer environment
5+ years of hands-on medical coding experience in a payer environment
5+ years of Strong expertise in ICD-10, CPT, and HCPCS coding methodologies and translation
5+ years of Strong understanding of anatomy, physiology, pharmacology, and medical terminology
3+ years clinical experience in a healthcare environment (strong clinical assessment and critical thinking skills.)
Experience supporting Medicaid operations and MMIS systems
Strong analytical, documentation, and business requirements gathering skills
Excellent written and verbal communication skills
Proficiency with Microsoft Office Suite
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.

Nice To Haves

5+ years of experience in policy remediation
5+ years of experience with claims processing systems
5+ years of Experience using: Optum Encoder, Other medical coding software platforms
3+ years of clinical experience in a healthcare environment
Strong clinical assessment and critical-thinking skills
Experience supporting government healthcare or managed care operations

Responsibilities

Serve as a subject matter expert (SME) for medical coding methodologies, Medicaid policy, and healthcare claims processing.
Support annual, quarterly, and ad hoc ICD-10, CPT, and HCPCS coding updates received from CMS.
Perform analysis of medical coding changes and assess impact on business processes, claims adjudication, and system functionality.
Conduct initial code reviews and determine the scope and business impact of coding updates.
Prepare and distribute coding change listings for review by Medicaid program teams and reference administration staff.
Collaborate with policy owners, stakeholders, developers, and business teams to support change requests and MMIS enhancements.
Participate in MMIS modernization and replacement project meetings, providing coding and business process expertise.
Research business rules, operational requirements, and process models to develop recommendations and solutions.
Maintain business rules, coding documentation, requirements repositories, and process documentation.
Facilitate meetings with agency personnel, stakeholders, and operational teams.
Support policy remediation efforts and ensure alignment between coding standards and operational workflows.
Assist with development and maintenance of training documentation and process materials.
May review patient records against established medical necessity criteria as backup support.
Work collaboratively with cross-functional teams supporting Medicaid operations and healthcare initiatives.