Job ID: SC-9815 (99990223)
Hybrid/Local Healthcare BA (RN must/CPC/CCS) with insurance/medical review/appeals, payor coding, clinical assessment, ICD/CPT/HCPCS, anatomy/pharmacology, policy remediation, claims processing, Optum Encode, ICD-10 experience
Location: Columbia, SC (SCDHHS)
Duration: 18 Months
Work Location: Hybrid (20% onsite – must be available to come onsite periodically)
Candidate Location: Candidate MUST be a SC resident. No relocation allowed.
Required Skills (rank in order of Importance):
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 a 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.
ADDITIONAL SKILLS:
5+ years written and oral communications skills, strong proficiency in English.
Preferred Skills (rank in order of Importance):
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 Certifications:
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.
Specific duties include, but are not limited to:
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 code 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 the 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.
SCMSP_Candidate_Cover_Sheet_Updated_08.2025 (2).docx