Business Analyst (Policy remediation) - Contract - Remote
About The Position
We are seeking an experienced Business Analyst with expertise in policy remediation, medical coding, and healthcare claims systems. This role will serve as a subject matter expert (SME) supporting policy and operational initiatives related to medical coding compliance, claims adjudication, and system change management. The ideal candidate will leverage deep knowledge of ICD-10, CPT, and HCPCS coding methodologies, as well as Medicaid and payer operations, to ensure alignment between policy updates, coding changes, and system functionality. This position will play a critical role in supporting compliance initiatives, regulatory updates, and business process improvements.
Requirements
- Minimum of 5 years of experience in healthcare insurance, medical review, program integrity, or appeals.
- At least 5 years of experience working with IT developers and programmers in a payer environment.
- Minimum of 5 years of hands-on experience in medical coding within a payer environment.
- Strong expertise in ICD-10, CPT, and HCPCS coding methodologies and translation.
- Minimum of 5 years of experience with medical claims processing systems.
- Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint).
- Experience using Optum Encoder or similar medical coding software.
- Strong analytical, problem-solving, and critical-thinking skills.
- Excellent written and verbal communication skills.
Nice To Haves
- Minimum of 5 years of experience in policy remediation.
- At least 3 years of clinical experience in a healthcare environment.
- Strong clinical assessment and critical-thinking skills.
- Experience with Medicaid programs and Medicaid Management Information Systems (MMIS).
- Familiarity with healthcare regulatory compliance and policy implementation.
Responsibilities
- Serve as a subject matter expert (SME) for medical coding methodologies, Medicaid policy, and claims adjudication processes.
- Analyze annual, quarterly, and ad hoc coding updates, including ICD-10, CPT, and HCPCS changes.
- Review and assess the impact of coding and policy changes on business processes, system functionality, and claims outcomes.
- Collaborate with business stakeholders, policy teams, and technical teams to define requirements and implement necessary system changes.
- Support change requests and ensure system updates produce accurate and expected claims adjudication results.
- Research business rules, requirements, and process models to develop recommendations and solutions.
- Maintain and update business rules, requirements documentation, and process models in designated repositories.
- Lead meetings with stakeholders, business owners, and cross-functional teams.
- Participate in policy remediation efforts, compliance initiatives, and related enterprise projects.
- Ensure process documentation, training materials, and supporting documentation are complete and up to date.
- Collaborate with internal teams to support ongoing operational and regulatory compliance.
- Provide expertise in medical coding software, claims systems, and healthcare policy interpretation.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
11-50 employees
