Your Role

The Facility Compliance Review team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events.. The Certified Clinical Coder Nurse, Senior will report to the Senior Manager, Facility Compliance Review. In this role you will be performing in-depth quality audits of hospital claims to support ICD-10-CM and ICD-10 PCS codes as well as MS-DRG and APR-DRG reviews based on clinical determination. You will review claims 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. 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. The ideal candidate will hold at least a CPC or CCS certification from AHIMA or AAPC, and higher-level certifications are highly desirable.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Requires coding certification: Active AAPC CIC or AHIMA COC certification with procedure coding experience (HCPCS/CPT)
• Requires familiarity with electronic health record (HER) systems and coding software
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Requires Oracle (Cerner) and Emergency Department EM leveling experience
• Strong analytical and problem-solving skills
• Requires advanced knowledge of job area typically obtained through advanced education combined with experience

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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