Clinical Systems Analyst

Job Description

Job Description

Location
Columbia, SC

Experience Level
Senior Level (10+ years in healthcare insurance; 5+ years in medical coding)

Role Overview
This dual-functioning IT Healthcare Consultant and Business Analyst role supports medical code change requests by researching, analyzing, and delivering recommendations to policy owners and stakeholders. Acting as a Subject Matter Expert (SME), the successful candidate will facilitate process improvements and system enhancements, bridging the gap between clinical requirements and IT implementation. This role is highly suited for a credentialed Registered Nurse (RN) and Certified Medical Coder who thrives in complex, change-oriented project environments.

Key Responsibilities

Medical Coding & Reference Maintenance
• Manage and initiate annual and quarterly updates from CMS for all ICD-10 and CPT/HCPCS coding changes.
• Perform initial reviews of code modifications to determine the scope of operational and system changes.
• Prepare detailed listings of code changes for review and analysis by program and administrative staff.
• Serve as the primary Subject Matter Expert (SME) for medical coding methodologies and related healthcare policies.

IT Collaboration & System Enhancements
• Participate as a core project team member for process improvements and enterprise claims system enhancements.
• Provide reference administration expertise for large-scale, future system replacement initiatives.
• Research and maintain business rules, technical requirements, and data models within central repositories.
• Collaborate continuously with IT developers and programmers to align clinical needs with system capabilities.

Stakeholder Engagement & Clinical Support
• Facilitate and conduct meetings with cross-functional personnel, stakeholders, and process owners.
• Partner with team members to ensure process documentation and training materials are comprehensive and routinely updated.
• Serve as a clinical back-up to review patient records against established criteria to determine medical necessity.

Required Qualifications
• Education: Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN).
• Licensure: Current, active, and unrestricted Registered Nurse (RN) license in the State of South Carolina.
• Certification: Active Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) credential.
• Certification: ICD-10 Proficiency demonstrated by exam (or the ability to become certified within one year of employment).
• 10+ years of experience in healthcare insurance, medical review, program integrity, or appeals.
• 5+ years of experience performing medical coding in a payer environment.
• 5+ years of experience working directly with IT developers and programmers in a payer environment.
• 3+ years of clinical experience in a healthcare setting.
• 5+ years of deep foundational knowledge in ICD/CPT/HCPCS translation, coding methodologies, anatomy, physiology, pharmacology, and medical terminology.

Preferred Qualifications
• 5+ years of experience in policy remediation.
• 5+ years of experience working with healthcare claims processing systems.
• 5+ years of experience utilizing Optum Encoder and/or other prominent medical coding software programs.
• Proficiency with Microsoft Office suite and standard business tools.

Core Skills & Attributes
• Strong clinical assessment and critical thinking capabilities.
• Ability to effectively translate complex clinical and coding rules into actionable IT requirements.
• Excellent verbal and written communication skills to engage and guide stakeholders at all levels.
• Proven capability to work collaboratively in a fast-paced, change-oriented team environment.

Flexible work from home options available.