Lead RN Clinical Coding & Compliance Analyst (Hybrid)

Blue Shield of CA; Portland (OR); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Blue Shield of CA is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review team by auditing hospital claims for ICD-10-CM/PCS coding accuracy and medical necessity. You will mentor a small team of coders, perform in-depth reviews, and guide training sessions to maintain high-quality coding and compliant billing practices.

The role requires CPC or CCS certification (or equivalent) with CA RN licensure or eligibility, and a proactive, detail-oriented leader who

Qualifications

• 7 years of prior relevant experience required.
• 3 years' inpatient coding experience required.
• One of the following certifications: CCS, CPC-CIC, RHIT, RHIA, CCDS or CDIP.
• Utilization management (UM) experience is required.
• Ability to analyze claim data analytics is required.

Responsibilities

• Review post-service prepayment facility claims for contract compliance and medical necessity.
• Lead a small clinical coder team and provide training and guidance.
• Review outpatient coding for injection and infusion billing.
• Ensure billed coding aligns with reimbursement requirements and quality standards.

Skills

Inpatient coding

Utilization management (UM) experience

Data analytics

Attention to detail

Independent motivation

Education

Associate's degree in nursing

Active CA RN license

Tools

Oracle Cerner

EHR systems

Job description

Blue Shield of CA is seeking a Clinical Coding Analyst RN, Consultant to support the Facility Compliance Review team by auditing hospital claims for ICD-10-CM/PCS coding accuracy and medical necessity. You will mentor a small team of coders, perform in-depth reviews, and guide training sessions to maintain high-quality coding and compliant billing practices.

The role requires CPC or CCS certification (or equivalent) with CA RN licensure or eligibility, and a proactive, detail-oriented leader who