Clinical Coding Analyst RN, Consultant

Blue Shield of CA; Oakland (CA); Hybride; USD 110 000 - 150 000; Plein temps

Résumé du poste

Blue Shield of California is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review team and a small coder group. You will review claims for medical necessity and coding accuracy, lead trainings, and supervise the coding process to ensure compliant reimbursement.

The role requires a CA RN license, 7 years of relevant experience, 3 years inpatient coding, and professional certifications (CCS/CPC-RHIT/RHIA/CDIP). Hybrid work with initial PST hours in CA.

Qualifications

• Associate's degree in nursing (required).
• Current unrestricted California RN license; other state license acceptable with CA within 90 days.
• 7 years of prior relevant experience.
• 3 years inpatient coding experience.
• One of CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP is required.
• Utilization management experience is required.
• Ability to analyze claim data analytics is required.
• Health plan experience (managed care) preferred.
• Strong attention to detail.
• Arbitration experience preferred.
• Independent motivation and strong computer navigation skills.
• Familiarity with EHR systems; Oracle Cerner and ED EM leveling experience preferred.

Responsabilités

• Lead and train the FCR team; mentor staff and coordinate refresher trainings.
• Review post-service prepayment facility claims for contract compliance and medical necessity.
• Audit outpatient coding for injection and infusion billing accuracy.
• Review medical records; perform coding analysis on diagnoses, procedures, DRG/APC and charge codes.
• Ensure billed coding aligns with reimbursement requirements and quality of care objectives.

Connaissances

Attention to detail

Independent motivation

Computer navigation

Leadership experience

Data analysis

Formation

CCS

CPC-CIC

RHIT

RHIA

CCDS

CDIP

CA RN license

Associate's degree in nursing

Outils

Oracle Cerner

Description du poste

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.

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.

Your Knowledge and Experience

• 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 required

• Health 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.