Project Overview
This is a long-running, multi-year effort that provides consulting services to operations and policy staff for the current MMIS. The focus of this role is to serve as a subject matter expert (SME), building knowledge that helps policy and process owners make the best recommendations for Medicaid members and providers. You will help staff understand CPT/HCPCS and ICD-10 coding and apply codes correctly within the Reference Administration sub-system.
Key Responsibilities
• Initiate annual and quarterly updates from CMS for all ICD-10 and CPT/HCPCS coding changes.
• Perform initial code reviews to determine the scope of changes.
• Prepare listings of code changes for Reference Administration and Medicaid Program staff to review and analyze.
• Conduct meetings with agency personnel, stakeholders, and process owners.
• Participate in replacement MMIS project meetings where reference administration expertise is needed.
• Serve as an SME for medical coding methodologies, Medicaid policy, and related topics.
• Research business rules, requirements, and models to complete initial analysis and recommendations.
• Maintain business rules, requirements, and models in a repository.
• Collaborate with the team to keep process documentation and stakeholder training content complete and up to date.
• Once fully proficient, serve as back-up for other roles in the bureau, including claim escalation research.
• Perform other project-related duties as assigned.
Required Skills
• 3+ years of experience in healthcare.
• Strong knowledge of ICD/CPT/HCPCS translation and coding methodologies.
• 3+ years of extensive knowledge of anatomy, physiology, pharmacology, and medical terminology.
• 3+ years of strong knowledge of formal business process documentation.
• Strong analytical skills and the ability to manage multiple work efforts at the same time.
• Ability to learn how medical codes link to claims processing.
• Ability to understand business and functional requirements.
• Strong time management, collaboration, and relationship-building skills.
• Excellent written and oral communication skills, with strong proficiency in English.
• Ability to communicate effectively with executive management, line management, project management, and team members.
Preferred Skills
• 3+ years of healthcare experience in hospital, office, or clinic settings.
• Proficiency with Microsoft Office (Word, Excel, PowerPoint), Optum Encoder, and other medical coding software.
• A clinical background is helpful but not required.
• Residence in SC, NC, or GA.
Education
• Bachelor's degree in a healthcare-related field.
• An equivalent combination of education and experience may be considered, subject to the Client's hiring team review and approval.
Required Certification
• Current credential as a CPC (Certified Professional Coder) or CCS (Certified Coding Specialist).