Clinical Analyst

We are seeking an Advanced Business Analyst / Clinical Analyst & Coding Specialist for a long-term contract role. This is a unique opportunity for a Registered Nurse (RN) with strong medical coding expertise to act as a Subject Matter Expert (SME), bridging the gap between clinical policy and IT systems.

Note: There is NO actual medical billing or coding in this role. You will be researching code data changes (CMS/ICD-10/CPT) and translating them into business rules and system requirements.

Logistics & Interview Process

• Work Arrangement: Fully Remote
• Location Requirements: Candidate MUST be a current South Carolina (SC) resident.
• Shift: EST
• Interview Process: 1 Round, Virtual/Online (Quick turnaround!)

Key Skills & Experience Required

• Payer Environment Expertise (5 Years): Experience working in healthcare insurance, medical review, program integrity, or appeals on the payer side (not just hospital/provider side).
• IT Collaboration (5 Years): Proven experience translating clinical needs into business/functional requirements and working directly with IT developers and programmers.
• Coding System Knowledge (5 Years): Strong knowledge of ICD-10, CPT, and HCPCS translation and coding methodologies.
• Clinical Background (3 Years): Strong clinical assessment and critical thinking skills.

Required Education, Licenses & Certifications

• Education: Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN).
• Licensure: Current, active, and unrestricted South Carolina RN License.
• Certification: Current CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) credential.

Highly Desired (Bonus Skills)

• 5 years of experience with Claims Processing Systems.
• 5 years of experience in Policy Remediation.
• Experience with Optum Encoder or other medical coding software.