Clinical Coding Analyst RN, Consultant

Blue Shield of CA; Washington; Hybrid; USD 100,000 - 150,000; Full time

Job summary

Blue Shield of CA seeks a Clinical Coding Analyst RN, Consultant to lead the Facility Compliance Review (FCR) team in post-service prepayment facility claims analysis for contract compliance and medical necessity. You will supervise a small clinical coder team, perform coding analyses across ICD-10-CM/PCS, EDC, MS-DRG and APR-DRG reviews, and contribute to training and process improvements.

The role requires California RN licensure, CCS/CPC-based certification, and leadership experience.

Qualifications

• Associate's degree in nursing required.
• Current unrestricted California RN License and/or in assigned states; CA license within 90 days if assigned an additional state.
• 7 years of prior relevant experience required.
• 3 years' inpatient coding experience required.
• Certification: CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP.
• Utilization management (UM) experience required.
• Health plan experience preferred.
• Strong attention to detail.

Responsibilities

• Lead capacity: review claims, train new hires, and support team development.
• Oversee quality audits of hospital claims for ICD-10-CM/PCS, ED coding, MS-DRG and APC reviews.
• Review outpatient coding for correctness of billing related to injections and infusions.
• Analyze medical records and coding to ensure reimbursement requirements and quality benchmarks are met.

Skills

Attention to detail

Independent motivation

Strong computer skills

EHR systems familiarity

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.