IT Clinical Analyst

• Competitive salary

• Support CPT, HCPCS, and ICD-10 code maintenance including annual and quarterly updates
• Review code changes to determine scope, impact, and required system updates
• Prepare code change documentation for review by program and policy staff
• Ensure alignment of coding changes with Medicaid policy and claims adjudication processes

• Serve as a subject matter expert for Medicaid systems, coding methodologies, and policy requirements
• Research and analyze business rules, requirements, and process models
• Maintain repositories of business rules, requirements, and system logic
• Provide recommendations to stakeholders to support decision-making and system improvements

• Apply clinical knowledge to support medical coding and policy interpretation
• Assist with review of patient records to determine medical necessity when required
• Ensure coding and system updates result in accurate claims processing outcomes

• Conduct meetings with stakeholders, agency staff, and process owners
• Collaborate with IT developers, policy staff, and operational teams
• Participate in system enhancement and modernization initiatives
• Support process improvements and ongoing program initiatives

• Maintain process documentation, training materials, and coding guidelines
• Ensure documentation is complete, accurate, and up to date
• Support reporting and communication of coding updates and system changes
• Contribute to governance, compliance, and policy alignment efforts

• Bachelor of Science in Nursing or Associate Degree in Nursing
• Active, unrestricted Registered Nurse license in South Carolina
• Current certification as Certified Professional Coder or Certified Coding Specialist
• Demonstrated ICD-10 proficiency or ability to obtain certification within one year
• 5 or more years of experience in healthcare insurance, medical review, program integrity, or appeals
• 5 or more years of experience working with IT developers or programmers in a payer environment
• 5 or more years of experience performing medical coding in a payer environment
• 3 or more years of clinical experience in a healthcare setting
• 5 or more years of experience with ICD, CPT, and HCPCS coding methodologies
• Strong knowledge of anatomy, physiology, pharmacology, and medical terminology
• Strong written and verbal communication skills
• Proficiency with Microsoft Office tools

• 5 or more years of experience supporting policy remediation initiatives
• 5 or more years of experience working with medical claims processing systems
• 5 or more years of experience with Optum Encoder or similar coding software
• Experience supporting government or managed care environments

• Strong analytical and critical thinking capabilities
• Ability to manage multiple concurrent work efforts
• Excellent communication and stakeholder engagement skills
• Strong collaboration and relationship-building abilities
• High attention to detail and accuracy in coding and documentation
• Ability to work effectively in a fast-paced, change-oriented environment

This is a remote position.