Lead Clinical Coding Analyst RN - ICD-10 & DRG Audits (Hybrid)

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

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.