IT Healthcare Consultant Business Analyst

Location: Remote but Candidate MUST be a SC resident - No relocation allowed




Position Overview
The State of South Carolina is seeking an experienced Registered Nurse (RN) with strong healthcare payer, medical coding, and business analysis experience to support Medicaid code maintenance and healthcare policy initiatives.
This role is focused on reviewing and analyzing CPT/HCPCS and ICD-10 coding updates received from CMS and internal initiatives. The position does not involve hands-on medical coding, but instead focuses on:

• Reviewing coding updates and coding data
• Performing research and impact analysis
• Making recommendations to policy and operational teams
• Supporting Medicaid MMIS enhancements and future MMIS replacement initiatives
• Acting as a Subject Matter Expert (SME) for medical coding methodologies and Medicaid policy

The ideal candidate will have experience working in healthcare insurance/payer environments, claims processing, medical review, and business rules analysis.Key Responsibilities

• Review annual and quarterly CMS updates for ICD-10 and CPT/HCPCS code changes
• Analyze code impacts and determine scope of changes
• Prepare coding change documentation for internal Medicaid teams
• Conduct meetings with stakeholders, process owners, and agency personnel
• Research business rules, requirements, and operational impacts
• Develop recommendations for policy and process improvements
• Maintain business rules and documentation repositories
• Collaborate with internal teams on MMIS enhancements and future MMIS replacement projects
• Serve as SME for:
  • Medical coding methodologies
  • Medicaid policy
  • Claims processing workflows
  • Reference administration
• Support process documentation and training material updates
• May assist with medical necessity reviews of patient records

Required Experience & Skills
Mandatory Qualifications

• 5+ years of experience in healthcare insurance, medical review, program integrity, or appeals
• 5+ years of medical coding experience in a payer environment
• 5+ years working with IT developers/programmers in healthcare payer systems
• Strong knowledge of:
  • ICD-10
  • CPT/HCPCS coding methodologies
  • Claims processing systems
  • Medical terminology
  • Anatomy, physiology, and pharmacology
• 3+ years of clinical healthcare experience
• Strong analytical, communication, and documentation skills
• Experience managing multiple priorities simultaneously
• Ability to write and understand business and functional requirements
• Strong collaboration and stakeholder management skills
• Proficiency with Microsoft Office Suite

Preferred Experience

• Experience with Medicaid policy remediation
• Experience with MMIS systems
• Experience with Optum Encoder or other coding software tools
• Government healthcare or managed care experience preferred

Required Education

• Bachelor of Science in Nursing (BSN) OR
• Associate Degree in Nursing (ADN)

Required Certifications

• Active, unrestricted RN license from the South Carolina Board of Nursing
• Current CPC (Certified Professional Coder) OR CCS (Certified Coding Specialist) certification
• ICD-10 proficiency certification preferred (or ability to obtain within 1 year)