Business Analyst (Advanced / Clinical Coding SME) - BA 26-01611

IT Healthcare Consultant Business Analyst (Advanced / Clinical Coding SME)

Location: Columbia, SC (Hybrid Approximately 20% onsite; must be available to report onsite periodically)
Duration: 12-Month Contract

Position Overview

We are seeking an experienced IT Healthcare Consultant Business Analyst (Advanced) to support a large-scale Medicaid Management Information System (MMIS) environment. This multi-year initiative focuses on providing strategic consulting and operational support to Medicaid policy and operations teams.

The selected candidate will serve as a Subject Matter Expert (SME) in medical coding methodologies, Medicaid policy, and payer-system processes, ensuring accurate code maintenance and regulatory compliance.

Responsibilities

• Initiate and manage annual and quarterly updates for ICD-10, CPT, and HCPCS coding changes

• Perform impact analysis to determine scope and downstream system implications

• Prepare detailed code change documentation for reference and program teams

• Facilitate meetings with stakeholders, policy owners, and technical teams

• Participate in MMIS modernization/replacement project discussions as a coding and reference administration SME

• Research and analyze business rules, system requirements, and operational models

• Maintain documentation repository for coding rules and policy requirements

• Collaborate with cross-functional teams to ensure process documentation and training materials remain current

• Provide backup support reviewing medical records to determine medical necessity, when required

• Perform additional project-related duties as assigned

Required Education

• Bachelor of Science in Nursing (BSN)
  OR

• Associate Degree in Nursing (ADN)

Required Certifications

• Active, unrestricted Registered Nurse (RN) license (State of South Carolina)

• Current credential as:

  • CPC (Certified Professional Coder) OR

  • CCS (Certified Coding Specialist)

• Demonstrated ICD-10 proficiency (or ability to obtain certification within one year)

Required Experience & Skills

• 5+ years healthcare insurance experience, including medical review, program integrity, or appeals

• 5+ years experience collaborating with IT developers/programmers within a payer environment

• 5+ years medical coding experience in a payer setting

• 3+ years clinical experience in a healthcare environment with strong assessment and critical thinking skills

• 5+ years expertise in ICD-10, CPT, and HCPCS translation and coding methodologies

• 5+ years knowledge of anatomy, physiology, pharmacology, and medical terminology

Preferred Qualifications

• 5+ years experience in policy remediation

• 5+ years experience with claims processing systems

• 5+ years Microsoft Office proficiency

• Experience with Optum Encoder or other medical coding software programs