Medical Coding Subject Matter Expert (SME)

Job Title: Medical Coding Subject Matter Expert (SME)

Location: 1628 Browning Rd, Columbia, SC 29210

Work Type: 75% Remote, 25% Onsite

Visa Requirement: Visa-independent candidates only

Position Overview

We are seeking a Medical Coding Subject Matter Expert (SME) with extensive experience in medical coding methodologies, healthcare insurance operations, and clinical healthcare environments. This role supports South Carolina’s Medicaid Management Information System (MMIS) by maintaining CPT/HCPCS and ICD-10 codes and providing expert guidance to policy, process owners, and system administrators.

The ideal candidate is highly knowledgeable in ICD/CPT/HCPCS coding, medical terminology, and healthcare policy and possesses outstanding communication and collaboration skills to engage with diverse stakeholders, including executive management and technical teams.

Scope of Work

This multi-year project focuses on providing consulting services to operations and policy staff for the current MMIS while laying the groundwork for the administrative approach to a replacement management system. The SME will act as a vital resource for medical coding updates, training, and process improvements.

Key Responsibilities

• Coding Updates:
• Initiate and review annual and quarterly coding updates (ICD-10, CPT/HCPCS) from CMS.
• Analyze the scope of coding changes and prepare detailed listings for internal review.
• Collaboration and Communication:
• Facilitate meetings with stakeholders, policy experts, and process owners.
• Serve as the agency’s medical coding SME, providing expert guidance on Medicaid policy and coding methodologies.
• Project Participation:
• Participate in DASH (Replacement MMIS) project meetings as needed.
• Research, analyze, and document business rules, requirements, and models.
• Maintain documentation repositories for business rules, processes, and training content.
• Training and Documentation:
• Collaborate with team members to ensure training content and process documentation are accurate, complete, and up to date.
• Conduct and document analysis, recommendations, and process updates.
• General Duties:
• Assist with program integrity, appeals, and claims processing.
• Support coding-related queries and other project-related duties.

Required Skills

• Healthcare and Insurance Expertise:
• 5 years in healthcare insurance, including medical review, program integrity, or appeals.
• Medical Coding:
• 5 years of experience in medical coding within a payer environment.
• Deep knowledge of ICD/CPT/HCPCS coding methodologies and translation.
• Clinical Experience:
• 3 years of clinical healthcare experience.
• Technical Collaboration:
• 5 years working with IT developers/programmers in a payor environment.
• Medical Knowledge:
• Extensive knowledge of anatomy, physiology, pharmacology, and medical terminology.
• Documentation:
• Proficiency in formal business process documentation.
• Communication:
• Exceptional written and oral communication skills.

Preferred Skills

• Policy and Claims:
• Experience with policy remediation and claims processing systems.
• Technical Tools:
• Proficiency in Microsoft Office (Word, Excel, PowerPoint) and medical coding software such as Optum Encoder.

Educational Requirements

• Required:
• RN or LPN with a Medical Coding Certification.

Required Certifications

• Current nursing license in South Carolina and/or multi-state license.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).
• ICD-10 Proficiency, demonstrated by exam or achieved within one year of employment.

Why Join Us?

This role provides the opportunity to leverage your medical coding expertise to impact Medicaid policies and operations significantly. Collaborate with top professionals to shape the administrative approach for South Carolina’s evolving Medicaid systems.

Equal Opportunity Employer Statement

We are an Equal Opportunity Employer and encourage applications from candidates of all backgrounds. We do not discriminate based on race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Job Type: Contract

Pay: $60.00 - $70.00 per hour

Expected hours: 40.00 per week

Schedule:

• 8 hour shift

Work Location: Hybrid remote in Columbia, SC 29210

Salary : $60 - $70