Clinical Coding Analyst RN, Consultant

Blue Shield of CA; Phoenix (AZ); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA seeks a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review (FCR) team in reviewing post-service prepayment facility claims for medical necessity and coding accuracy. You will lead a small clinical coder team and train new hires under the Senior Manager, Facility Compliance Review.

The role requires a California RN license, CPC/CCS or similar certification, 7 years of relevant experience including inpatient coding, and UM experience.

Qualifications

• Associate's degree in nursing is required.
• Current unrestricted California RN License and/or in assigned states; CA license within 90 days if additional state.
• 7 years of prior relevant experience
• 3 years' inpatient coding experience
• Certification: CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP
• Utilization management (UM) experience is required
• Ability to analyze claim data analytics is required
• Health plan/managed care experience preferred
• Familiarity with EHR systems (Cerner) preferred

Responsibilities

• Lead capacity assisting with reviewing claims, training new hires, and providing team support.
• Review hospital and outpatient coding for accuracy, DRG/APC and charge codes.
• Ensure billed coding aligns with reimbursement requirements and quality goals.
• Review medical records and perform coding analysis for ICD-10-CM/PCS, EDC, MS-DRG and APR-DRG reviews.
• Mentor a small clinical coder team and support continuous learning.

Skills

Leadership experience

Analytical skills

Attention to detail

Independent motivation

EHR familiarity

Strong computer navigation

Education

Associate's degree in nursing

Tools

Oracle Cerner

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.

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.