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

Blue Shield of CA; Miami (FL); Hybrid; USD 90,000 - 110,000; Full time

Job summary

Blue Shield of California is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review (FCR) team. You will review post-service prepayment facility claims for contract compliance, medical necessity, DRG/EDC reviews, and outpatient coding for injection and infusion billing; lead a small coding team and train new hires.

The role requires a California RN license, 7 years of experience, 3 years inpatient coding, and one of CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP;

Qualifications

• Associate's degree in nursing is required.
• 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.
• 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

• Lead and review claims coding and perform audits with the FCR team.
• Train new hires and facilitate refresher trainings, acting as a resource for the team.
• Review outpatient coding for injection and infusion billing.
• Analyze claim data analytics to ensure compliant coding and reimbursement.
• Support a small clinical coder team of 2 in quality audits and workflow improvements.

Skills

Leadership experience

Attention to detail

Independent motivation

Analytical skills

Computer navigation

EHR familiarity

Education

Associate's degree in nursing

CA RN license

Tools

Oracle Cerner

Job description

Blue Shield of California is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review (FCR) team. You will review post-service prepayment facility claims for contract compliance, medical necessity, DRG/EDC reviews, and outpatient coding for injection and infusion billing; lead a small coding team and train new hires.

The role requires a California RN license, 7 years of experience, 3 years inpatient coding, and one of CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP;