Healthcare Consultant

InfoStride; Columbia (SC); On-site; USD 100,000 - 130,000; Full time

Benefits offered by this job

Microsoft Office

Job summary

A leading healthcare consulting firm is seeking an IT Healthcare Consultant – Business Analyst to support coding updates and maintain medical coding methodologies. The role requires at least 5 years of healthcare insurance experience and clinical background, alongside strong analytical skills. Candidates should possess a Bachelor's degree in Nursing and have relevant certifications. A hybrid work model is offered, with occasional onsite presence required. The position is for 12 months, with potential for extension.

Qualifications

• 5+ years in healthcare insurance; medical review, program integrity, or appeals.
• 5+ years working with IT developers/programmers in a payor environment.
• 3+ years clinical experience in a healthcare environment (strong clinical assessment and critical thinking skills).
• 3+ years clinical experience in a healthcare environment.
• 5+ years knowledge of ICD/CPT/HCPCS translation and coding methodologies.
• 5+ years knowledge of anatomy, physiology, pharmacology, and medical terminology.

Responsibilities

• Initiates annual updates from CMS of all coding changes.
• Prepares listings of code changes for review and analysis.
• Serves as agency subject matter expert for medical coding methodologies.
• 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.

Skills

Healthcare insurance experience

Medical review and program integrity

Clinical assessment

Critical thinking skills

Knowledge of ICD/CPT/HCPCS coding

Knowledge of anatomy and physiology

Clinical assessment

Education

Bachelor of Science in Nursing (BSN)

Associate Degree in Nursing (ADN)

Tools

Microsoft Office

Optum Encoder

Job description

Job Title: IT Healthcare Consultant – Business Analyst – Advanced

Location: 1801 Main Street, Columbia, South Carolina 29201

Work Arrangement: Hybrid (20% Onsite Required)

Duration: 12 Months (Possible Extension)

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.

Required Skill

• 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.

Preferred Skill

• 5+ years’ experience in policy remediation.
• 5+ years claims processing systems experience.
• 5+ years knowledge of Microsoft Office
• 5+ years Optum Encoder and/or other medical coding software programs

Required Education

• Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)

Required Certification

• 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.