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Skills

ICD-10
CPT
HCPCS
Registered Nurse
CPC
CCS
Optum Encoder
Claims Processing Systems
Medicaid Management Information Systems
MMIS
Clinical Analysis
Medical Review
Program Integrity
Policy Remediation
Business Analysis

Summary

Requirements

10 or more years of experience in healthcare insurance operations, medical reviews, or program integrity.
Proficiency in ICD-10, CPT, and HCPCS medical coding translation methodologies.
Experience with clinical nursing operations and possessing an active Registered Nurse (RN) licensure.
Experience in a healthcare payer environment collaborating directly with software developers and programmers.
Experience with specialized medical coding software such as Optum Encoder and enterprise claims processing systems.
Experience in clinical policy remediation, medical necessity reviews, and patient chart assessments.
Excellent verbal and written communication skills.

Responsibilities

Conduct annual and quarterly clinical review updates of national coding change datasets from regulatory health authorities.
Formulate initial system impact analyses for newly introduced medical, procedural, and diagnostic codes.
Translate complex clinical policy and healthcare regulatory updates into systematic functional specifications for database systems.
Partner with application developers and software engineers to optimize state-level healthcare payer systems.
Oversee medical code repositories, reference data catalogs, and system business rules databases.
Evaluate patient records against established clinical criteria to determine medical necessity and payment eligibility.
Coordinate interdisciplinary project meetings to communicate technical code revisions and operational changes to stakeholders.

Founded in 1999, Resourcesoft, Inc. is a leading Technology Consulting and Professional Services organization. Headquartered in Marlborough, MA, the company serves the technology needs of its clients nationwide. Resourcesoft has often been recognized by prominent rating agencies for its exemplary growth and stability. With over two decades of industry experience, the Company has evolved as a front runner in enabling project optimization. We partner with leading organizations to provide technology solutions within the financial, insurance, education, government, publishing, healthcare and pharmaceutical domains. We take pride in mentoring a workforce that is well positioned to respond to the emerging IT trends and needs. With the employees at the crux of every business endeavor, our success is driven by our expertise in pairing the right talent with the best jobs in the technology sector. We forge long term, personalized relationships with our employees to advance their career to the next level. We engage them in technology centric client projects that provide opportunities for them to evolve, innovate and deliver world class products and services. Our career opportunities offer challenging assignments and exposure to emerging and cutting edge technologies. We are committed to providing our employees with the tools necessary to accelerate their career progression, while maintaining a healthy, work-life balance. We are deeply committed to providing a workplace ambience that is both challenging and fulfilling.

Resourcesoft is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.

For more information about Resourcesoft and our services, please visit our website.

Employers have access to artificial intelligence language tools (“AI”) that help generate and enhance job descriptions and AI may have been used to create this description. The position description has been reviewed for accuracy and Dice believes it to correctly reflect the job opportunity.

Dice Id: 10117734
Position Id: 21770-27990-
Posted 1 day ago

Company Info

About Resourcesoft, Inc.

Founded in 1999, Resourcesoft, Inc. is a leading Technology Consulting and Professional Services organization. Headquartered in Marlborough, MA, the company serves the technology needs of its clients nationwide. Resourcesoft has often been recognized by prominent rating agencies for its exemplary growth and stability. With over two decades of industry experience, the company has evolved as a front runner in enabling project optimization. We partner with leading organizations to provide technology solutions within the financial, insurance, education, government, publishing, healthcare and pharmaceutical domains. We take pride in mentoring a workforce that is well positioned to respond to the emerging IT trends and needs. With the employees at the crux of every business endeavor, our success is driven by our expertise in pairing the right talent with the best jobs in the technology sector. We forge long term, personalized relationships with our employees to advance their career to the next level. We engage them in technology centric client projects that provide opportunities for them to evolve, innovate and deliver world class products and services. Our career opportunities offer challenging assignments and exposure to emerging and cutting edge technologies. We are committed to providing our employees with the tools necessary to accelerate their career progression, while maintaining a healthy, work-life balance. We are deeply committed to providing a workplace ambience that is both challenging and fulfilling.

Healthcare Systems Analyst

Hybrid in Columbia, South Carolina

•

Today

Requirements 7 or more years of experience in commercial healthcare systems and business analysis. Proficiency in public health insurance payer system integration and MITA business architecture principles. Experience with Electronic Data Interchange (EDI) standards, transaction sets, and database schemas. Experience in translating complex business processes into detailed functional specifications. Experience with federal technology certification requirements and system validation processes. Expe

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Clinical Systems Analyst (CPC/CCS)

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Clinical Systems Analyst (CPC/CCS)

Resourcesoft, Inc.

Job Details

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Summary

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About Resourcesoft, Inc.

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