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.

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.

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.

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.

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.

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.