Lead Clinical Coding RN – ICD-10 & Claims Audit

Blue Shield of CA; Virginia Beach (VA); 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 team. You will lead a small coding group, review claims for medical necessity and proper ICD-10 coding, and provide training and guidance to staff.

The role emphasizes leadership, data analytics, and deep knowledge of hospital coding standards while aligning with payer requirements and quality programs.

Qualifications

• Associate's degree in nursing is required.
• Current unrestricted California RN License and/or in assigned states; CA license within 90 days if assigned other state.
• 7 years of prior relevant experience.
• 3 years' inpatient coding experience.
• Certified CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP required.
• Utilization management (UM) experience.
• Ability to analyze claim data analytics.
• Health plan experience preferred.
• Familiarity with EHR, Oracle Cerner, and ED EM leveling preferred.

Responsibilities

• Lead a small clinical coding team and train new hires.
• Review post-service prepayment facility claims for compliance.
• Ensure billed codes align with reimbursement and coding standards.
• Perform quality audits of hospital claims for ICD-10-CM/PCS.
• Review outpatient coding for injections and infusions billing.
• Lead with independent motivation and strong work ethic.

Skills

Data analytics

Leadership

Attention to detail

Independent work

Education

Associate's degree in nursing

Tools

Cerner EHR

Oracle

Job description

Blue Shield of CA is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review team. You will lead a small coding group, review claims for medical necessity and proper ICD-10 coding, and provide training and guidance to staff.

The role emphasizes leadership, data analytics, and deep knowledge of hospital coding standards while aligning with payer requirements and quality programs.