Clinical Coding Analyst RN, Senior

21 hours ago


Long Beach, United States Blue Cross and Blue Shield Association Full time

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.



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