Clinical Analyst & Coding Specialist - Contract - Columbia, SC
SUNSHINE ENTERPRISE USA LLC•Columbia, SC
•Hybrid
About The Position
Seeking an experienced Business Analyst (Clinical Analyst & Coding Specialist) to support ongoing Medicaid operations and healthcare system initiatives. The consultant will serve as a Subject Matter Expert (SME) for medical coding, Medicaid policy, and business analysis while collaborating with business and technical teams to support coding updates, policy implementation, and business process improvements.
Requirements
- 10+ years of experience in healthcare insurance, medical review, program integrity, or appeals.
- 5+ years working with IT developers/programmers in a payer environment.
- 5+ years of medical coding experience in a payer environment.
- 3+ years of clinical experience in a healthcare environment.
- Strong knowledge of ICD-10, CPT, and HCPCS coding methodologies.
- Strong knowledge of anatomy, physiology, pharmacology, and medical terminology.
- Experience gathering business requirements and documenting business processes.
- Excellent analytical, communication, and stakeholder management skills.
- Candidate MUST be a SC resident.
Nice To Haves
- Experience with healthcare policy remediation.
- Claims processing systems experience.
- Microsoft Office Suite proficiency.
- Experience with Optum Encoder or other medical coding software.
- Medicaid and healthcare payer systems experience.
- Experience supporting healthcare system modernization initiatives.
Responsibilities
- Coordinate annual and quarterly ICD-10, CPT, and HCPCS code updates.
- Review and analyze coding changes to determine business and operational impacts.
- Prepare code change documentation for stakeholder review.
- Collaborate with business users, stakeholders, and technical teams to implement coding and policy updates.
- Participate in meetings related to healthcare systems modernization initiatives.
- Serve as a Subject Matter Expert (SME) for medical coding methodologies and Medicaid-related processes.
- Research business rules, requirements, and workflows to develop recommendations.
- Maintain business rules, process documentation, and requirements repositories.
- Support process documentation, knowledge transfer, and training activities.
- Review medical records against established criteria to determine medical necessity when required.
- Assist with additional healthcare and project-related initiatives.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
