Hybrid RN: ICD-10 & DRG Coding Lead

Blue Shield of California; California (MO); 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 coding team and review post-service claims for ICD-10-CM/PCS coding, medical necessity reviews, and DRG/ED determinations.

You will train staff, conduct audits, and ensure accurate outpatient coding and infusion billing in a hybrid work setting. CA RN license with CPC/CCS or equivalent credentials is required.

Qualifications

• Requires an Associate’s degree in nursing and CA RN license.
• 7 years of relevant experience in healthcare coding or auditing.
• 3 years inpatient coding experience required.
• Certification: CCS/CPC-CIC/RHIT/RHIA(CCDS/CDIP) or equivalent.
• UM experience and claim data analytics required.
• Familiarity with Electronic Health Records (EHR) systems; Oracle (Cerner) experience preferred.

Responsibilities

• Prepare and present cases to Medical Director for oversight and determination.
• Develop and review member documentation reflecting determinations per regulatory standards.
• Lead small clinical coder team; manage daily activities and train staff.
• Perform clinical review of post-service inpatient, outpatient and ER claims.
• Ensure billing accuracy and compliance with reimbursement requirements.
• Assist with audits, training, and escalation management.

Skills

Utilization management experience

Claim data analytics

Leadership experience

EHR familiarity

Arbitration experience

Independent motivation

Strong computer navigation

Education

Associate’s degree in nursing

Tools

Oracle Cerner

Job description

Blue Shield of California is seeking a Clinical Coding Analyst RN, Consultant to lead a small clinical coding team and review post-service claims for ICD-10-CM/PCS coding, medical necessity reviews, and DRG/ED determinations.

You will train staff, conduct audits, and ensure accurate outpatient coding and infusion billing in a hybrid work setting. CA RN license with CPC/CCS or equivalent credentials is required.