IT Healthcare Consultant – Business Analyst : The South Carolina Department of Health & Human Servi

ShiftCode Analytics, Inc. is seeking an IT Healthcare Consultant – Business Analyst for the South Carolina Department of Health & Human Services. The role involves assisting with CPT/HCPCS and ICD-10 code maintenance, conducting reviews of coding data, and providing recommendations to policy and process owners.

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

Requirements:

• 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
• Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)
• 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
• 5+ years' experience in policy remediation
• 5+ years claims processing systems experience
• 5+ years Optum Encoder and/or other medical coding software programs