Note: The job is a remote job and is open to candidates in USA. Blue Shield of California is a nonprofit health plan focused on creating a sustainably affordable healthcare system. The Clinical Coding Analyst RN, Consultant supports facility compliance review by analyzing inpatient, outpatient, and emergency department claims for coding accuracy, medical necessity, reimbursement compliance, and quality of care. The role also leads a small clinical coding team, provides training, supports denial and appeal strategies, and serves as a resource for escalations and cross-functional collaboration.
Responsibilities
- 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
Skills
- 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
- Strong attention to detail
- Requires independent motivation, solid work ethic, and strong computer navigation skills
- The ideal candidate will have previous leadership experience
- The ideal candidate will have ... at least a CPC or CCS certification from AHIMA or AAPC
- Health plan experience (managed care) preferred
- Arbitration experience preferred
- Familiarity with electronic health record (EHR) systems, Oracle (Cerner) and Emergency Department EM leveling experience preferred
- Higher-level certifications are highly desirable
Benefits
- Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially.
- For most teams, this means coming into the office two days per week.
- This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
- The workplace model provides flexibility.
Company Overview