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.

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