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.

Responsibilities

Your Work

In this role, you will:

Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to 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 and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
Lead duties for small clinical coder team including managing day to day activities of the team, motivating the team to achieve the organizational goals, monthly auditing, attending team huddles and training when needed
Performs clinical review of post service inpatient, outpatient and ER claims for appropriateness of coding
Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
Clinical judgment and detailed knowledge of benefit plans used to complete review decisions
Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on DRG and is able to impart this knowledge to physicians and other health team members.
Willingness to learn multiple EMR systems to retrieve medical records as needed
Leverages national data and remains current with payer trends needed to educate and lead team to achieve benchmark performance
Acts as a resource and helps to validate post claim DRG downgrade denials related to coding and clinical determination to support appeal strategy, tracking by disease, payer and denial activity and works with teams to create transparency and improvements to mitigate and prevent denials
This person will have clear communication, be collaborative, while working effectively and efficiently
Represent team at cross-functional meetings and be a point of contact for escalations.
Strong understanding and proficiency of reimbursement methodology, federal, state and payor coding documentation and billing requirements
Other job duties as assigned

Qualifications

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.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun 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 Ascendiun 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 health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is 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 one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by 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.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

For most teams, this means coming into the office two days per week.
Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Blue Shield of California

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Clinical Coding Analyst RN, Consultant