Registered Nurse

Hybrid/Local Registered Nurse (RN & CPC/CCS & BSN/ADN must) with Medicaid, Medical coding/Optum Encode, clinical assessment, ICD/CPT/HCPCS, anatomy/physiology/pharmacology terminology, claims, ICD-10 experience.

Location:

Columbia, SC (SCDHHS). Duration: 18 Months.

Work Location:

Hybrid (20% onsite; must be able to come onsite periodically). Candidate must be a South Carolina resident; relocation not permitted.

• 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 a 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.

• 5+ years written and oral communication skills, strong proficiency in English.

• 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.

Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN).

• 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 of employment.

• 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 code 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 the 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.