Lead Clinical Coding RN for Facility Compliance and Audits

Blue Shield of CA; Baltimore (MD); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review (FCR) team in auditing facility claims for ICD-10-CM/PCS coding, medical necessity, and DRG reviews.

The role involves leading a small coder team, training new hires, and ensuring accurate outpatient coding for injections/infusions while aligning with reimbursement and quality goals.

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.
• 3 years' inpatient coding experience.
• Certification in CCS/CPC-CIC/RHIT/RHIA/CDDS or CDIP required.
• Utilization management (UM) experience is required.
• Experience with EHR systems (Cerner) and EM leveling in ED is preferred.

Responsibilities

• Review post-service prepayment facility claims for compliance and medical necessity.
• Lead a small clinical coding team, train new hires, and provide reference for the team.
• Ensure billed coding aligns with reimbursement requirements and quality goals.
• Review outpatient coding for injection/infusion billing accuracy.
• Lead coding analyses on diagnoses, procedures, DRG/APC, and charge codes.

Skills

7 years of experience

3 years inpatient coding

Utilization management

Claim data analytics

EHR/Cerner familiarity

Strong attention to detail

Education

Associate's degree in nursing

CA RN license / state license with CA eligibility within 90 days

CCS or CPC-CIC or RHIT or RHIA or CCDS or CDIP

Job description

Blue Shield of CA is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review (FCR) team in auditing facility claims for ICD-10-CM/PCS coding, medical necessity, and DRG reviews.

The role involves leading a small coder team, training new hires, and ensuring accurate outpatient coding for injections/infusions while aligning with reimbursement and quality goals.