IT Healthcare Consultant (Hybrid) - Columbia, SC
About the position A leading healthcare organization is seeking an experienced IT Healthcare Consultant – Business Analyst (Advanced) to support a multi-year Medicaid systems initiative. This role will serve as a Clinical Analyst and Medical Coding Subject Matter Expert (SME), partnering with operations, policy, and IT teams to support ongoing enhancements and modernization efforts related to the Medicaid Management Information System (MMIS). Responsibilities • Medical Coding & Regulatory Governance Lead annual and quarterly CMS updates for ICD-10, CPT, and HCPCS codes • Analyze coding changes to determine scope, system impact, and business implications • Develop and distribute documentation outlining coding updates to program stakeholders • Serve as SME on coding methodologies and Medicaid policy alignment • Business Analysis & Documentation Research and document business rules, workflows, and system requirements • Maintain centralized repository of coding and policy documentation • Provide regulatory and operational recommendations to stakeholders • Support initiatives related to MMIS enhancements and replacement platform efforts • Stakeholder Engagement Facilitate meetings with agency leadership, program teams, and technical staff • Translate clinical and coding requirements into functional specifications • Assist with training materials and knowledge transfer initiatives • Collaborate cross-functionally with policy, compliance, operations, and IT teams • Clinical & Compliance Support Review medical records for medical necessity and coding validation when required • Support claims review, policy remediation, and compliance initiatives • Assist in claims and coding validation processes to ensure regulatory adherence Requirements • Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) • Active, unrestricted Registered Nurse license (State of South Carolina) • Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) • ICD-10 proficiency certification (or ability to obtain within one year) • 5+ years of healthcare payer/insurance experience (medical review, program integrity, appeals, etc.) • 5+ years collaborating with IT developers/programmers in a payer environment • 5+ years of hands-on medical coding experience (ICD-10, CPT, HCPCS) • 3+ years of clinical healthcare experience • Strong knowledge of anatomy, physiology, pharmacology, and medical terminology Nice-to-haves • Experience with policy remediation initiatives • Experience with claims processing systems • Familiarity with medical coding software (e.g., Optum Encoder or similar tools) • Proficiency with Microsoft Office Suite