Senior IT healthcare consultant (RN/CPS/CSS)

Location: Columbia, SC | Position type: W2 contract

About the Role

We are seeking an experienced IT Healthcare Consultant Business Analyst to support healthcare technology initiatives involving business process analysis, requirements management, system enhancements, and stakeholder collaboration. The ideal candidate will have strong experience in healthcare insurance environments, particularly with claims, medical review, coding, and payer systems, along with the ability to bridge clinical, business, and technical teams.

Responsibilities

• Serve as a liaison between healthcare business stakeholders, clinical teams, and IT development teams.
• Analyze business and clinical requirements and translate them into detailed functional and technical specifications.
• Work closely with software developers and programmers in a healthcare payer environment.
• Analyze, document, and improve business processes related to healthcare claims, medical review, coding, appeals, and program integrity.
• Support the design, enhancement, and remediation of healthcare policies and payer systems.
• Analyze claims processing workflows and identify opportunities for system and process improvements.
• Apply knowledge of ICD-10, CPT, and HCPCS coding methodologies to support business and system requirements.
• Review medical coding and clinical information to ensure requirements and system functionality align with applicable healthcare policies.
• Collaborate with development teams to define system changes, enhancements, and defect resolutions.
• Support requirements gathering, analysis, validation, testing, and implementation activities throughout the SDLC.
• Analyze system and business impacts associated with policy changes and regulatory requirements.
• Develop business rules, functional specifications, process documentation, and requirements traceability artifacts.
• Support testing and validation of healthcare applications, claims processing systems, and coding-related functionality.
• Use healthcare coding software and related tools to research and validate medical coding information.
• Communicate findings, recommendations, project status, and technical requirements to business and IT stakeholders.
• Participate in troubleshooting, root-cause analysis, system remediation, and continuous process improvement initiatives.

Requirements

• Bachelor's or Associate degree in Nursing, or equivalent healthcare/clinical education.
• Current, active, and unrestricted Registered Nurse (RN) license in the applicable state.
• Current CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) certification, or ability to obtain the required certification within one year.
• 10+ years of experience in healthcare insurance, medical review, program integrity, appeals, or related payer operations.
• 5+ years of experience working with IT developers/programmers in a healthcare payer environment.
• 5+ years of medical coding experience within a payer environment.
• 3+ years of clinical healthcare experience with strong clinical assessment and critical-thinking skills.
• 5+ years of experience with ICD, CPT, and HCPCS translation and coding methodologies.
• 5+ years of knowledge of anatomy, physiology, pharmacology, and medical terminology.
• 5+ years of experience with healthcare policy remediation.
• 5+ years of experience with claims processing systems.
• Strong knowledge of Microsoft Office applications.
• 5+ years of experience using Optum Encoder or comparable medical coding software.
• Strong analytical, problem-solving, documentation, and communication skills.
• Ability to effectively communicate between clinical, business, and technical teams.

Preferred Qualifications

• Experience supporting large-scale healthcare payer system implementations or modernization initiatives.
• Experience with healthcare claims administration and adjudication platforms.
• Experience working with medical review, utilization management, appeals, or program integrity systems.
• Experience developing and validating healthcare business rules.
• Experience with Agile and/or Waterfall SDLC methodologies.
• Experience supporting system testing, UAT, defect management, and production remediation.
• Strong understanding of healthcare regulations, payer policies, and medical coding standards.