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 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 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.

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.