Clinical Analyst & Coding Specialist

Clinical Analyst & Coding Specialist

Job Description

SCOPE OF THE PROJECT:
This project is a multi-year effort which primarily focuses on providing consulting services to operations and policy staff for the current Medicaid Management Information System (MMIS).
The current position’s focus and priority is the continued support of serving as a subject matter expert (SME), building knowledge that allows policy and process owners to make the best recommendations for Medicaid members and providers.

OBJECTIVES TO BE FULFILLED BY CANDIDATE:
The principal duties of this position are to assist with the CPT/HCPCS and ICD-10 code maintenance. As the IT Healthcare Consultant – Business Analyst – Advanced (Clinical Analyst and Coding Specialist):

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 codes changes to Reference Administration staff and Medicaid Program staff for review and analysis.
Conducts meetings with the client personnel, stakeholders, and process owners.
(Future) Participates in DASH (Replacement MMIS) project meetings, as needed, where reference administration expertise is required.
Serves as the client 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.
5+ years written and oral communications skills, strong proficiency in English.
Knowledge of Microsoft Office Suite

This position requires an individual with strong analytical skills and experience in:
Managing multiple work efforts simultaneously
Medical Coding
Nursing
Time management skills
CPT/HCPCS and ICD-10 translation
Ability to write and understand business and functional requirements.
The candidate must have strong collaboration and relationship building skills.
Experience in healthcare insurance

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 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 SKILLS (RANK IN ORDER OF IMPORTANCE):
5+ years’ experience in policy remediation.
5+ years claims processing systems experience.
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 client 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.

Notes:
Fully Remote

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.