Nurse Clinical Coding Analyst - RN, Consultant

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 125,000 - 160,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

Blue Shield of CA is seeking a Clinical Coding Analyst RN, Consultant to lead the Facility Compliance Review team, train new hires, and support audits of hospital claims for ICD-10-CM/PCS, DRG/APC, and EDC reviews. The role includes ensuring accurate outpatient coding related to injections and infusions and working with a small coder team.

The ideal candidate will hold at least CPC or CCS certification (AHIMA or AAPC) and have leadership experience with strong analytical skills and familiarity

Qualifications

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

Responsibilities

• Lead and train the FCR team; provide refresher trainings as needed.
• Review outpatient coding for injection and infusion billing accuracy.
• Review medical records and perform coding analysis for diagnoses, procedures, DRG/APC, and charges.
• Ensure billed coding aligns with reimbursement, research, and quality-of-care standards.

Skills

Claim data analytics

Leadership experience

Attention to detail

Education

Associate's degree in nursing

Tools

Cerner/Oracle EHR

Job description

Your Role

The Facility Compliance Review (FCR) team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events. The Clinical Coding Analyst RN, Consultant will report to the Senior Manager, Facility Compliance Review. In this role you will be supporting the FCR team in addition to a small clinical coder team of 2 clinical coders who will be responsible for performing in-depth quality audits of hospital claims to support ICD-10-CM and ICD-10 PCS codes as well as EDC (Emergency Department Coding), MS-DRG and APR-DRG reviews based on clinical determination. Reviews will also be performed for medical necessity and to meet the criteria for the coding billed. You will also be responsible for reviewing outpatient coding for appropriateness of billing related to injection and infusions. This person will review medical records and perform coding analysis on all diagnoses, procedures, DRG/APC and charge codes. Ensure that the billed coding is appropriate based on reimbursement requirements, research, epidemiology, financial and strategic planning and evaluation of quality of care. In this role you will be working in a Lead capacity assisting with reviewing claims, training new hires, facilitating refresher trainings for the team as needed, and being a resource for the team to ask questions. The ideal candidate will have previous leadership experience and hold at least a CPC or CCS certification from AHIMA or AAPC, and higher-level certifications are highly desirable.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

We are a CA based company and training hours for the first few months will be 8am-5pm PST. After that, this person can work 6am-3pm, 7am-4pm or 8am-5pm PST.

Your Knowledge and Experience

• Associate's degree in nursing is required
• Current unrestricted California RN License and/or in assigned states. If assigned an additional state, they must obtain the CA RN license (in addition to primary assigned state license) within 90 days of hire
• 7 years of prior relevant experience required
• 3 years' inpatient coding experience required
• One of the following is required: Certified Coding Specialist (CCS), Certified Professional Coder (CPC-CIC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Documentation Integrity Specialist (CCDS) or Certified Documentation Integrity Practitioner (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
• Strong attention to detail

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.