active, and non-restricted licensure by the State of South

Team Size:

8+

Company / Department culture:

The South Carolina Department of Health & Human Services (SCDHHS) is the State Medicaid Agency for South Carolina. 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.

Why is this position open (new role, increased workload, new dept., resignation, promotion)?

The workload and complexities of the reference administration responsibilities requires additional support to maintain efficiency and to achieve defined deliverable dates. The additional position will allow us to finalize succession planning for team members that may consider retirement within the next 12 – 18 months.

This position requires an individual with strong analytical skills and experience in:

Ø  Managing multiple work efforts simultaneously

Ø  Medical Coding

Ø  Nursing

Ø  Time management skills

Ø  CPT/HCPCS and ICD-10 translation

Ø  Ability to write and understand business and functional requirements.

• Please ensure that your candidates have strengths in these areas. Please do not submit general Medical Coders with no structured background in business rules or claims processing, preferably Government Operations and Managed Care background.
• The candidate must have strong collaboration and relationship building skills.
• Experience in healthcare insurance

Scope of the project:

This project is a multi-year effort which primarily focuses on providing consulting services to operations and policy staff for the current Medicaid Management Information System (MMIS).

The current position’s focus and priority is the continued support of serving as a subject matter expert (SME), building knowledge that allows policy and process owners to make the best recommendations for Medicaid members and providers.

Position:

IT Healthcare Consultant – Business Analyst - Advanced

Pre-employment Checks?

State mandatory - Criminal, Credit and E-Verify background checks

Objectives to Be Fulfilled by Candidate:

The principal duties of this position are to assist with the CPT/HCPCS and ICD-10 code maintenance. As the IT Healthcare Consultant – Business Analyst – Advanced (Clinical Analyst and Coding Specialist):

Specific duties include, but are not limited to:

• 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 Skills (rank in order of Importance):

·         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.

Preferred Skills (rank in order of Importance):

• 5+ years’ experience in policy remediation.

• 5+ years claims processing systems experience.
• 5+ years Optum Encoder and/or other medical coding software programs

Required Education:

Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)

Required Certifications:

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.