Clinical Coding Analyst RN, Consultant

Blue Shield of California; California; Hybrid; USD 112,000 - 167,000; Full time

Job summary

Blue Shield of California is seeking a Clinical Coding Analyst RN, Consultant to lead a small clinical coder team and review post-service claims for coding accuracy and medical necessity. The role supports the Facility Compliance Review program, leveraging ICD-10-CM/PCS knowledge and UM experience to drive quality outcomes.

The role requires CA RN licensure, 7 years of relevant experience, and appropriate coding certifications; hybrid virtual work with occasional in-office needs in California.

Qualifications

• Nursing degree required with active California RN license.
• 7 years of relevant healthcare experience.
• 3 years of inpatient coding experience required.
• One of CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP certifications required or highly desirable.
• Utilization management (UM) experience required.
• Experience with EHR systems (Oracle Cerner) preferred.
• Health plan experience in managed care preferred.
• Strong attention to detail and analytical skills.
• Independent motivation and solid work ethic.
• Familiarity with medical coding guidelines and payor requirements.

Responsibilities

• Prepare and present cases to Medical Director for oversight and necessity determinations.
• Develop and review member-centered documentation reflecting determinations and ensure regulatory compliance.
• Lead a small clinical coder team, manage daily activities, and coordinate training.
• Perform clinical review of post-service inpatient, outpatient, and ER claims for coding appropriateness.
• Ensure certifications/licenses are up-to-date and compliant.
• Identify potential quality-of-care issues and delays, intervening as needed.
• Provide guidance on DRG/APC impact and coding decisions for appeals.
• Support cross-functional meetings and escalate issues as needed.

Skills

Leadership

Attention to detail

Analytical thinking

Communication

Independent motivation

Regulatory compliance

Education

Associate’s degree in nursing

Tools

Oracle Cerner (EHR)

Job description

Your Role

The Facility Compliance Review (FCR) team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events. The Clinical Coding Analyst RN, Consultant will report to the Senior Manager, Facility Compliance Review. In this role you will be supporting the FCR team in addition to a small clinical coder team of 2 clinical coders who will be responsible for performing in-depth quality audits of hospital claims to support ICD-10-CM and ICD-10 PCS codes as well as EDC (Emergency Department Coding), MS-DRG and APR-DRG reviews based on clinical determination. Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for reviewing outpatient coding for appropriateness of billing related to injection and infusions. This person will review medical records and perform coding analysis on all diagnoses, procedures, DRG/APC and charge codes. Ensure that the billed coding is appropriate based on reimbursement requirements, research, epidemiology, financial and strategic planning and evaluation of quality of care. In this role you will be working in a Lead capacity assisting with reviewing claims, training new hires, facilitating refresher trainings for the team as needed, and being a resource for the team to ask questions. The ideal candidate will have previous leadership experience and hold at least a CPC or CCS certification from AHIMA or AAPC, and higher-level certifications are highly desirable.

Job Description

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

We are a CA based company and training hours for the first few months will be 8am-5pm PST. After that, this person can work 6am-3pm, 7am-4pm or 8am-5pm PST.

Responsibilities

• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
• Lead duties for small clinical coder team including managing day to day activities of the team, motivating the team to achieve the organizational goals, monthly auditing, attending team huddles and training when needed
• Performs clinical review of post service inpatient, outpatient and ER claims for appropriateness of coding
• Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
• Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions
• Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on DRG and is able to impart this knowledge to physicians and other health team members.
• Willingness to learn multiple EMR systems to retrieve medical records as needed
• Leverages national data and remains current with payer trends needed to educate and lead team to achieve benchmark performance
• Acts as a resource and helps to validate post claim DRG downgrade denials related to coding and clinical determination to support appeal strategy, tracking by disease, payer and denial activity and works with teams to create transparency and improvements to mitigate and prevent denials
• This person will have clear communication, be collaborative, while working effectively and efficiently
• Represent team at cross-functional meetings and be a point of contact for escalations.
• Strong understanding and proficiency of reimbursement methodology, federal, state and payor coding documentation and billing requirements
• Other job duties as assigned

Qualifications

• Associate’s degree in nursing is required
• Current unrestricted California RN License and/or in assigned states. If assigned an additional state, they must obtain the CA RN license (in addition to primary assigned state license) within 90 days of hire
• 7 years of prior relevant experience required
• 3 years’ inpatient coding experience required
• One of the following is required: Certified Coding Specialist (CCS), Certified Professional Coder (CPC-CIC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Documentation Integrity Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP)
• Utilization management (UM) experience is required
• Ability to analyze claim data analytics is requiredHealth plan experience (managed care) preferred
• Strong attention to detail
• Arbitration experience preferred
• Requires independent motivation, solid work ethic, and strong computer navigation skills
• Familiarity with electronic health record (EHR) systems, Oracle (Cerner) and Emergency Department EM leveling experience preferred
• Strong attention to detail

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About Us

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

JOB INFO

Job Identification : 20261961
Job Category : Healthcare Services and Operations
Posting Date : 2026-10-07T19:53:31+00:00
Job Schedule : Full time
Locations :
Long Beach, CA, United States
WA, United States
OH, United States
DC, United States
CA, United States
AZ, United States
CO, United States
CT, United States
FL, United States
GA, United States
MD, United States
MN, United States
NV, United States
AL, United States
IL, United States
VA, United States
TX, United States
Pay Range for California : $111540.00 to $167420.00
Pay Range for Bay Area : $125736.00 to $188728.00
Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
Role can be filled by a candidate requiring sponsorship : No