Clinical Analyst & Coding Specialist

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.

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.

·        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.

·        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.

·        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.

·        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.