Business Analyst - Advanced

Roles/Responsibilities:

• 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.

Mandatory Skill:

1. Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)
2. Must have current, active, and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.
3. 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.
4. 5+ years in healthcare insurance; medical review, program integrity, or appeals.
5. 5+ years working with IT developers/programmers in a payor environment.
6. 5+ years Medical Coding in payer environment
7. 3+ years clinical experience in a healthcare environment (strong clinical assessment and critical thinking skills.)
8. 5+ years knowledge of ICD/CPT/HCPCS translation and coding methodologies.
9. 5+ years knowledge of anatomy, physiology, pharmacology, and medical terminology.

Desirable Skills:

1. 5+ years' experience in policy remediation.
2. 5+ years claims processing systems experience.
3. 5+ years knowledge of Microsoft Office
4. 5+ years Optum Encoder and/or other medical coding software programs
5. Must have current, active, and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.
6. 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.