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 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 External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.