Current jobs related to Clinical Coding Analyst RN, Senior - Woodland Hills - Blue Shield of CA
-
Business Analyst, Senior
2 months ago
Woodland Hills, United States Blue Shield of California Full timeYour Role The Utilization Management (UM) Business Processing team supports the reporting and analytical needs of the CalPERS UM Teams. The Business Analyst, Senior will report to the Sr. Manager, Business Process Management. In this role you will provide complex analytical support to the CalPERS UM team, including, but not limited to CalPERS required...
-
Clinical Quality Analytics Senior
4 weeks ago
El Dorado Hills, California, United States Blue Shield of CA Full timeJob SummaryThe Clinical Quality Analytics Senior will play a key role in delivering best-in-class clinical quality analytics and informatics to enable high-quality and affordable member-centered care at Blue Shield of California. This position will provide data, analytic, and reporting support for the Clinical Quality Department to improve quality...
-
Business Analyst, Senior
3 weeks ago
Woodland Hills, United States Blue Shield of California Full timeYour Role The Utilization Management (UM) Business Processing team supports the reporting and analytical needs of the CalPERS UM Teams. The Business Analyst, Senior will report to the Sr. Manager, Business Process Management. In this role you will provide complex analytical support to the CalPERS UM team, including, but not limited to CalPERS required...
-
Senior Financial Analyst
3 weeks ago
Far Hills, United States Hire Point Recruiting Full timeAbout the job Senior Financial Analyst (2208961) Job Overview: A Senior FP&A Analyst is needed to support a growing finance department. This role involves key responsibilities in financial analysis, reporting, and business partnership, working cross-functionally to drive the financial strategy for the organization. The candidate will work closely with...
-
Senior Financial Analyst
1 month ago
Vernon Hills, United States Creative Financial Staffing Full timeOur client, a well-known manufacturing company is seeking a Senior Financial Analyst to join their growing Finance department. Great opportunity for an individual seeking growth and development. Why Work For This Company as a Senior Financial Analyst: Fantastic culture + profit sharing People development- lots of growth from within Great work life...
-
Senior Financial Analyst
3 weeks ago
Vernon Hills, United States Creative Financial Staffing Full timeOur client, a well-known manufacturing company is seeking a Senior Financial Analyst to join their growing Finance department. Great opportunity for an individual seeking growth and development. Why Work For This Company as a Senior Financial Analyst: Fantastic culture + profit sharing People development- lots of growth from within Great work life balance...
-
Business Analyst, Senior
2 weeks ago
Woodland Hills, CA, United States Blue Shield of California Full timeYour Role The Utilization Management (UM) Business Processing team supports the reporting and analytical needs of the CalPERS UM Teams. The Business Analyst, Senior will report to the Sr. Manager, Business Process Management. In this role you will provide complex analytical support to the CalPERS UM team, including, but not limited to CalPERS required...
-
Senior Data Analyst
4 weeks ago
Auburn Hills, Michigan, United States The Contingent Plan Full timeJob Title: Senior Data AnalystAbout the Role:The Contingent Plan is seeking a Senior Data Analyst to join our team. As a Senior Data Analyst, you will be responsible for serving as a link between data, systems, and providing process support for system SMEs to gain input/knowledge on key systems data.Responsibilities:Develop functional requirements for system...
-
Senior Software Developer
4 weeks ago
Woodland Hills, Utah, United States Athene Full timeAbout the Role:Athene is seeking a skilled Senior Software Developer to join our team. As a Senior Software Developer, you will be responsible for building efficient back-end features in Java/Python & SQL (primarily PostgresSQL). You will also build and maintain APIs, design, code, test, debug, document and implement changes to new and existing software...
-
Senior Call Center Technology Analyst
3 weeks ago
Agoura Hills, United States PennyMac Financial Services, Inc. Full timeThe Senior Call Center Technology Analyst will provide internal technical support across multiple applications and systems employed by telephony and other support teams. As the Senior Analyst, you will monitor and analyze internal agent behavior, pho Technology, Call Center, Analyst, Senior Analyst, Technical Support, Project Management
-
Senior Financial Analyst IL
2 days ago
vernon hills, United States Creative Financial Staffing Full timeOur client, a well-known manufacturing company is seeking a Senior Financial Analyst to join their growing Finance department. Great opportunity for an individual seeking growth and development. Why Work For This Company as a Senior Financial Analyst: Fantastic culture + profit sharing People development- lots of growth from within Great work life...
-
Senior Financial Analyst
4 weeks ago
Far Hills, New Jersey, United States Hire Point Recruiting Full timeAbout the JobA Senior Financial Analyst is needed to support a growing finance department at Hire Point Recruiting. This role involves key responsibilities in financial analysis, reporting, and business partnership, working cross-functionally to drive the financial strategy for the organization.The candidate will work closely with various departments,...
-
Senior Utilization Management Nurse
4 weeks ago
Woodland Hills, Utah, United States Blue Shield of CA Full timeYour RoleThe Facility Compliance Review team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events.In this role, you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care.You will also be...
-
Senior Business Analyst
1 month ago
Woodland, United States LTIMindtree Full timeAbout Us:LTIMindtree is a global technology consulting and digital solutions company that enables enterprises across industries to reimagine business models, accelerate innovation, and maximize growth by harnessing digital technologies. As a digital transformation partner to more than 700+ clients, LTIMindtree brings extensive domain and technology expertise...
-
Senior Business Analyst
1 month ago
Woodland, United States LTIMindtree Full timeAbout Us:LTIMindtree is a global technology consulting and digital solutions company that enables enterprises across industries to reimagine business models, accelerate innovation, and maximize growth by harnessing digital technologies. As a digital transformation partner to more than 700+ clients, LTIMindtree brings extensive domain and technology expertise...
-
Senior Application Security and Risk Specialist
4 weeks ago
Woodland Hills, California, United States Ekman Associates Full timeJob Title: Senior Application Security and Risk SpecialistLocation: RemoteEkman Associates is a management consulting firm that specializes in developing business, digital, and technology strategy, delivering solutions, and addressing human resource demands.Our team is looking for a Senior Application Security and Risk Specialist with extensive product...
-
Senior Estimator
4 weeks ago
Woodland Hills, California, United States Trillium Staffing Full timeJob Summary:Trillium Staffing is seeking a highly skilled Senior Estimator to join our team. As a Senior Estimator, you will be responsible for preparing estimates and bids for construction projects, working closely with clients and architects to understand project requirements.Key Responsibilities:Gathering quotes and prices from vendors and...
-
Senior Financial Systems Analyst
2 months ago
Auburn Hills, United States UHY LLP, Certified Public Accountants Full timeA great UHY client is seeking a Senior Financial Systems Analyst to join their team. The ideal candidate will have OneStream or HFM experience, Financial Systems experience, and familiarity with scripting languages (like Visual Basic and Python).The Senior Financial Systems Analyst is a hybrid position, with 2 days in the office (usually Mon and Wed). This...
-
Level V Sr RN-Clinic
3 weeks ago
Woodland Hills, United States Kaiser Permanente Full timeJob Summary: Functions as a Lead of the healthcare team, coordinates departmental operations that ensure quality patient care in a safe, healing environment that is patient and family centered. Demonstrates responsibility and accountability for own professional practice. Has appropriate clinical skills to be an expert resource. Is available and supportive to...
-
Senior Director, Risk Adjustment and Medicare STARs
2 months ago
Woodland Hills, United States Blue Shield of California Full timeYour Role The Senior Director, Risk Adjustment and Medicare STARs role will lead the Medicare Risk Adjustment and Stars programs, two functions that drive appropriate revenue and thus critical to the growth and financially viable and competitive Medicare products. This leader will develop the programs and take accountability by partnering with C-suite...
Clinical Coding Analyst RN, Senior
1 month ago
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 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 Medi-cal
- 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
- Performs clinical review of post service inpatient claims for appropriateness of MS-DRG based on severity of illness within the time frame and frequency as required
- 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.
- 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.
- 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 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.
#LI-MM4
