Lead Clinical Coding Analyst RN (Hybrid)

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

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.