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, Lead/Consultant will report to the Senior Manager, Facility Compliance Review. In this role you will be leading 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 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. 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 have previous leadership experienced and hold at least a CPC or CCS certification from AHIMA or AAPC, and higher-level certifications are highly desirable.

Your Work

In this role, you will:

• Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• 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, delegating as appropriate.
• 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
• Works collaboratively with vendors to assure performance expectations are being met
• 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.
• Clearly communicates, is collaborative, while working effectively and efficiently
• Perform monthly team audits
• Responsible for inventory management, documentation, training, compliance and identifying areas of process improvement
• Represent team at cross-functional meetings and be a point of contact for escalations.
• Maintains accuracy of diagnosis code assignment and productivity levels while insuring that all data is entered and recorded as directed
• Strong understanding and proficiency of reimbursement methodology, federal, state and payor coding documentation and billing requirements
• Must have knowledge of ICD-10-CM inpatient and outpatient coding
• Demonstrate knowledge and experience with CCI edits, payer edits, and payer policies, including Medicare NCD and LCDs.
• Review Facility ED claims for diagnosis, procedure, injection and infusion coding accuracy

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN License
• Requires at least 7 years of prior relevant experience
• One of the following is required: Certified Coding Specialist (CCS), Certified Professional Coder (CPC-CIC), Certified Coding Specialist (CCS) Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Documentation Integrity Specialist (CCDS), or Certified Documentation Integrity Practitioner (CDIP) Requires strong attention to detail to include ability to analyze claim data analytics
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Arbitration experience preferred
• Requires familiarity with electronic health record (EHR) systems, Oracle (Cerner) and Emergency Department EM leveling experience
• At least 2 years of Supervisory and/or leadership experience preferred
• At least 3 years inpatient coding experience required
• Arbitration experience preferred

Pay Range:

The pay range for this role is: $ 109120.00 to $ 163680.00 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.

#LI-MM4