Clinical Coding Analyst RN, Consultant

Blue Shield of CA; Virginia Beach (VA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review team. You will lead a small coding group, review claims for medical necessity and proper ICD-10 coding, and provide training and guidance to staff.

The role emphasizes leadership, data analytics, and deep knowledge of hospital coding standards while aligning with payer requirements and quality programs.

Qualifications

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

Responsibilities

• Lead a small clinical coding team and train new hires.
• Review post-service prepayment facility claims for compliance.
• Ensure billed codes align with reimbursement and coding standards.
• Perform quality audits of hospital claims for ICD-10-CM/PCS.
• Review outpatient coding for injections and infusions billing.
• Lead with independent motivation and strong work ethic.

Skills

Data analytics

Leadership

Attention to detail

Independent work

Education

Associate's degree in nursing

Tools

Cerner EHR

Oracle

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.