Clinical Coding Analyst RN, Consultant

About the 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 support the FCR team and a small clinical coder team of 2 clinical coders, performing in-depth quality audits of hospital claims to support ICD-10-CM, ICD-10 PCS codes, EDC (Emergency Department Coding), MS-DRG, and APR-DRG reviews based on clinical determination. Reviews will also assess medical necessity and coding billed criteria. You will review outpatient coding for appropriateness of billing related to injections and infusions, analyze medical records, and ensure billed coding aligns with reimbursement requirements, research, epidemiology, financial and strategic planning, and quality of care evaluation.

This role includes lead responsibilities such as reviewing claims, training new hires, facilitating refresher trainings, and serving as a resource for the team. The ideal candidate will have previous leadership experience and hold at least a CPC or CCS certification from AHIMA or AAPC, with higher-level certifications highly desirable.

Training hours for the first few months will be 8am–5pm PST. Afterward, the schedule options are 6am–3pm, 7am–4pm, or 8am–5pm PST.

Responsibilities

• Prepare and present cases to the Medical Director (MD) for medical director oversight and necessity determination; communicate determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
• Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards; identify potential quality of care issues, service or treatment delays, and intervene as clinically appropriate.
• Lead duties for a small clinical coder team, including managing day-to-day activities, motivating the team to achieve organizational goals, conducting monthly audits, attending team huddles, and providing training as needed.
• Perform clinical reviews of post-service inpatient, outpatient, and ER claims for appropriateness of coding.
• Stay current and comply with state and federal regulations/statutes and company policies impacting the area of responsibility; ensure certifications and/or licenses are up-to-date and valid prior to expiration dates.
• Identify potential quality of care issues, service, or treatment delays as clinically appropriate; apply clinical judgment and detailed knowledge of benefit plans to complete review decisions.
• Demonstrate an understanding of complications, comorbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, and the impact of procedures on DRG; impart this knowledge to physicians and other health team members.
• Learn multiple EMR systems to retrieve medical records as needed.
• Leverage national data and remain current with payer trends to educate and lead the team to achieve benchmark performance.
• Act as a resource and help validate post-claim DRG downgrade denials related to coding and clinical determination to support appeal strategy; track by disease, payer, and denial activity; work with teams to create transparency and improvements to mitigate and prevent denials.
• Communicate clearly, collaborate effectively, and represent the team at cross-functional meetings as a point of contact for escalations.
• Apply a strong understanding and proficiency in reimbursement methodology, federal, state, and payer coding documentation, and billing requirements.
• Perform other job duties as assigned.

Requirements

• Associate’s degree in nursing is required.
• Current unrestricted California RN License and/or in assigned states; if assigned an additional state, 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 of inpatient coding experience required.
• One of the following certifications 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.
• 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.

Schedule

This is a full-time role. Training hours for the first few months will be 8am–5pm PST. Afterward, schedule options are 6am–3pm, 7am–4pm, or 8am–5pm PST.

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

Pay

Pay range for California: $111,540.00 to $167,420.00.

Pay range for Bay Area: $125,736.00 to $188,728.00.

Note: This range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Salaries are based on candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

About Us

As of January 2025, Blue Shield of California became a subsidiary of Ascendium. Ascendium is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendium Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming healthcare to lower costs, improve quality, and enhance the member and physician experience. Our leadership model focuses on developing great leaders at all levels and creating opportunities for personal, professional, and financial growth. We foster an environment where all employees can thrive and contribute fully to address the needs of the communities we serve.

Blue Shield is recognized as a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company, and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company and by Points of Light as one of the 50 most community-minded companies in the United States.

Our values are:

• Honest: We hold ourselves to the highest ethical and integrity standards, building trust by doing what we say and acknowledging and correcting where we fall short.
• Human: We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous: We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.