Lead Clinical Coding Analyst RN - Audits & Compliance

Minority Professional Network, Inc.; Long Beach (CA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of California seeks a Clinical Coding Analyst RN, Consultant to lead a small clinical coder team and perform in-depth coding analyses for ICD-10-CM/PCS, EDC, MS-DRG and APR-DRG reviews. The role includes ensuring billing accuracy, medical necessity, and regulatory compliance across inpatient, outpatient, and ER claims.

You will support the Facility Compliance Review (FCR) team, train new hires, and serve as a resource for complex cases, while maintaining leadership responsibilities

Qualifications

• Associate's degree in nursing is required.
• Current unrestricted California RN License and/or in assigned states.
• 7 years of prior relevant experience.
• 3 years' inpatient coding experience.
• One of the following certifications: CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP.
• Utilization management (UM) experience is required.
• Ability to analyze claim data analytics.
• Health plan experience (managed care) preferred.
• Strong attention to detail.
• Familiarity with electronic health record (EHR) systems, Oracle (Cerner).

Responsibilities

• Prepare and present cases to Medical Director for oversight and necessity determinations.
• Develop and review member-centered documentation reflecting determinations.
• Lead duties for a small clinical coder team including day-to-day activities and audits.
• Perform clinical review of post-service inpatient, outpatient and ER claims for coding accuracy.
• Stay current with state and federal regulations and company policies.
• Identify potential quality of care issues and intervenes as appropriate.
• Communicate clearly and collaborate with physicians and health team members.
• Assist with reviewing post-claim DRG downgrade denials and support appeal strategy.

Skills

Leadership experience

Coding analysis

Communication

Problem solving

Education

Associate's degree in nursing

Tools

EHR systems

Oracle Cerner

Job description

Blue Shield of California seeks a Clinical Coding Analyst RN, Consultant to lead a small clinical coder team and perform in-depth coding analyses for ICD-10-CM/PCS, EDC, MS-DRG and APR-DRG reviews. The role includes ensuring billing accuracy, medical necessity, and regulatory compliance across inpatient, outpatient, and ER claims.

You will support the Facility Compliance Review (FCR) team, train new hires, and serve as a resource for complex cases, while maintaining leadership responsibilities