Lead Clinical Coding Analyst RN - ICD & Compliance (Hybrid)

Blue Shield of CA; Denver (CO); Hybrid; USD 95,000 - 125,000; Full time

Job summary

Blue Shield of California is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review team in reviewing post-service prepayment facility claims for contract compliance, medical necessity, and hospital-acquired conditions. The role includes leading a small clinical coding team of two coders, auditing ICD-10-CM/PCS codes, and DRG/APC reviews to ensure correct billing.

The role also involves training new hires, delivering refresher trainings, and acting as a

Qualifications

• Associate's degree in nursing is required.
• Current unrestricted California RN License and/or in assigned states.
• 7 years of prior relevant experience required.
• 3 years' inpatient coding experience required.
• One of the following is required: CCS, CPC-CIC, RHIT, RHIA, CCDS or 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.

Responsibilities

• Review post-service prepayment facility claims for contract compliance and medical necessity.
• Lead a small clinical coding team and train new hires.
• Review outpatient coding for injection and infusion billing.
• Review medical records and perform coding analysis for diagnoses, DRG/APC and charge codes.
• Ensure billed coding aligns with reimbursement requirements and quality evaluation.

Skills

Leadership experience

Attention to detail

Data analytics

EHR familiarity

Education

Associate's degree in Nursing

RN License (CA or state)

Tools

Cerner

Oracle

Job description

Blue Shield of California is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review team in reviewing post-service prepayment facility claims for contract compliance, medical necessity, and hospital-acquired conditions. The role includes leading a small clinical coding team of two coders, auditing ICD-10-CM/PCS codes, and DRG/APC reviews to ensure correct billing.

The role also involves training new hires, delivering refresher trainings, and acting as a