Job ID: SC-7)
Remote Clinical Analyst/Coding Specialist (SC RN/CPC/CCS) with ICD-10/CPT/HCPCS, Optum Encoder, payer/insurance, and claims processing systems, anatomy/physiology/pharmacology experience
Location: Columbia, SC (SCDHHS)
Duration: 12 Months
Required Skills
– Certification: Must have current, active, and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.
– Education: Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)
– Certification: 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.
– Education: 5+ years in healthcare insurance; medical review, program integrity, or appeals.
– Experience: 5+ years working with IT developers/programmers in a payor environment.
– Education: 5+ years Medical Coding in payer environment
– Experience: 3+ years clinical experience in a healthcare environment (strong clinical assessment and critical thinking skills.)
– Education: 5+ years knowledge of ICD/CPT/HCPCS translation and coding methodologies.
– Experience: 5+ years knowledge of anatomy, physiology, pharmacology, and medical terminology.
– Required Skills (Ranked in Order of Importance):
1. 5+ years in healthcare insurance; medical review, program integrity, or appeals.
2. 5+ years working with IT developers/programmers in a payor environment.
3. 5+ years Medical Coding in payer environment
4. 3+ years clinical experience in a healthcare environment (strong clinical assessment and critical thinking skills.)
5. 5+ years knowledge of ICD/CPT/HCPCS translation and coding methodologies.
6. 5+ years knowledge of anatomy, physiology, pharmacology, and medical terminology.
Preferred Skills
– Experience: 5+ years experience in policy remediation.
– Experience: 5+ years claims processing systems experience.
– Experience: 5+ years Optum Encoder and/or other medical coding software programs
Job 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.
– 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
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