Clinical Analyst & Coding Specialist

**About Sunshine Enterprise USA LLC**

We strive to be the premier national business solution for our clients, associates and business partners.

**Connecting Great Companies with Great People**

Founded on the principle that the right person in the right role can change everything, SEU-USA is more than just a staffing agency. Consequently, we are a strategic partner dedicated to building the powerful workforces that drive business success across the USA.

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**Clinical Analyst & Coding Specialist**

**Location:** Columbia, SC Hybrid (80% remote, onsite for required trainings and meetings).

**Interview Process:** 1 round, Virtual/Online

**Duration:** 12 Months

**Employment Type:** Contract

**Experience Required:** 10+ Years

**Candidate location:** Candidate MUST be a SC resident. No relocation allowed.

**Project Scope:**

Seeking an experienced **Business Analyst (Clinical Analyst & Coding Specialist)** to support ongoing Medicaid operations and healthcare system initiatives. The consultant will serve as a Subject Matter Expert (SME) for medical coding, Medicaid policy, and business analysis while collaborating with business and technical teams to support coding updates, policy implementation, and business process improvements.

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**Key Responsibilities:**

· Coordinate annual and quarterly ICD-10, CPT, and HCPCS code updates.

· Review and analyze coding changes to determine business and operational impacts.

· Prepare code change documentation for stakeholder review.

· Collaborate with business users, stakeholders, and technical teams to implement coding and policy updates.

· Participate in meetings related to healthcare systems modernization initiatives.

· Serve as a Subject Matter Expert (SME) for medical coding methodologies and Medicaid-related processes.

· Research business rules, requirements, and workflows to develop recommendations.

· Maintain business rules, process documentation, and requirements repositories.

· Support process documentation, knowledge transfer, and training activities.

· Review medical records against established criteria to determine medical necessity when required.

· Assist with additional healthcare and project-related initiatives.

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**Required Skills & Experience:**

· 10+ years of experience in healthcare insurance, medical review, program integrity, or appeals.

· 5+ years working with IT developers/programmers in a payer environment.

· 5+ years of medical coding experience in a payer environment.

· 3+ years of clinical experience in a healthcare environment.

· Strong knowledge of ICD-10, CPT, and HCPCS coding methodologies.

· Strong knowledge of anatomy, physiology, pharmacology, and medical terminology.

· Experience gathering business requirements and documenting business processes.

· Excellent analytical, communication, and stakeholder management skills.

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**Preferred Skills:**

· Experience with healthcare policy remediation.

· Claims processing systems experience.

· Microsoft Office Suite proficiency.

· Experience with Optum Encoder or other medical coding software.

· Medicaid and healthcare payer systems experience.

· Experience supporting healthcare system modernization initiatives.

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**Education**

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

**Certification:**

· Active, unrestricted Registered Nurse (RN) license.

· Current CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) certification.

· ICD-10 proficiency certification or ability to obtain certification within one year.