• Job Description

  Req#: 455829000022111112
  Job Description
  Business Analyst (Policy remediation)
  Location: Remote
  
  Interview Process: 1 round, virtual
  
  Duration: 12 MonthsEmployment Type: ContractExperience Required: 05+ Years
  
  Candidate Location: Candidate MUST be a SC resident. No relocation allowed.
  
  Project Scope:
  
  We are seeking an experienced Business Analyst with expertise in policy remediation, medical coding, and healthcare claims systems. This role will serve as a subject matter expert (SME) supporting policy and operational initiatives related to medical coding compliance, claims adjudication, and system change management.
  
  The ideal candidate will leverage deep knowledge of ICD-10, CPT, and HCPCS coding methodologies, as well as Medicaid and payer operations, to ensure alignment between policy updates, coding changes, and system functionality. This position will play a critical role in supporting compliance initiatives, regulatory updates, and business process improvements.
  
  Key Responsibilities:
  • Serve as a subject matter expert (SME) for medical coding methodologies, Medicaid policy, and claims adjudication processes.
  • Analyze annual, quarterly, and ad hoc coding updates, including ICD-10, CPT, and HCPCS changes.
  • Review and assess the impact of coding and policy changes on business processes, system functionality, and claims outcomes.
  • Collaborate with business stakeholders, policy teams, and technical teams to define requirements and implement necessary system changes.
  • Support change requests and ensure system updates produce accurate and expected claims adjudication results.
  • Research business rules, requirements, and process models to develop recommendations and solutions.
  • Maintain and update business rules, requirements documentation, and process models in designated repositories.
  • Lead meetings with stakeholders, business owners, and cross-functional teams.
  • Participate in policy remediation efforts, compliance initiatives, and related enterprise projects.
  • Ensure process documentation, training materials, and supporting documentation are complete and up to date.
  • Collaborate with internal teams to support ongoing operational and regulatory compliance.
  • Provide expertise in medical coding software, claims systems, and healthcare policy interpretation.
  
  Required Skills & Experience:
  • Minimum of 5 years of experience in healthcare insurance, medical review, program integrity, or appeals.
  • At least 5 years of experience working with IT developers and programmers in a payer environment.
  • Minimum of 5 years of hands-on experience in medical coding within a payer environment.
  • Strong expertise in ICD-10, CPT, and HCPCS coding methodologies and translation.
  • Minimum of 5 years of experience with medical claims processing systems.
  • Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint).
  • Experience using Optum Encoder or similar medical coding software.
  • Strong analytical, problem-solving, and critical-thinking skills.
  • Excellent written and verbal communication skills.
  
  Preferred Skills:
  • Minimum of 5 years of experience in policy remediation.
  • At least 3 years of clinical experience in a healthcare environment.
  • Strong clinical assessment and critical-thinking skills.
  • Experience with Medicaid programs and Medicaid Management Information Systems (MMIS).
  • Familiarity with healthcare regulatory compliance and policy implementation.
  
  Technical Skills
  
  Medical Coding and Reimbursement, ICD-10, CPT, and HCPCS Expertise, Policy Remediation and Compliance, Claims Adjudication and Processing, Medicaid and MMIS Knowledge, Business Requirements Analysis, Process Documentation and Improvement, Stakeholder Engagement and Facilitation, Regulatory and Operational Compliance, Cross-Functional Collaboration
  
  Education:
  
  Bachelor's degree in Health Information Management, Healthcare Administration, Business, or a related field.

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