Senior Coding Analyst

Full Time
Main Location
Durham, NC, United States
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Job Description

Seeking a highly motivated Senior Coding Analyst to join the Clinical Coding team. You will have the opportunity to provide technical, clinical and coding expertise to support coding related projects. You will consult and collaborate with all plan areas regarding national coding standards and applicability to Blue Cross NC's claims processing systems and reimbursement policy. As well as present findings and trends in coding practices to internal/external audiences and makes recommendations regarding coding standards.

  • Provide consultative expertise to other areas (e.g. Compliance, Claims Operations, Legal, Network Management, third party vendors and Medical Policy) regarding current and emerging coding/documentation issues.
  • Develop policies and standard operating procedures for the Healthcare division, which impact multiple business areas to ensure compliance with regulatory agencies, state and federal law and ensure consistency of reviews and operations.
  • Obtain and maintain all Clinical Code sets as issued from CMS, AMA and ADA.
  • Collaborate with multiple business areas to determine & ensure proper coding logic in the claims processing systems, based on member benefits & existing guidelines
  • Acts as a knowledge resource to pricing & expense analyst regarding charge/pricing related issues, providing processing and programming recommendation
  • Identify trends in coding practices to internal/external audiences and make recommendations regarding coding standards.
  • Assimilate necessary documentation, including medical records, and apply clinical coding expertise to evaluate appropriateness of provider coding and assess medical necessity of services rendered with referral to Medical Director as appropriate.
  • Gather appropriate claims data, analyze and prepare summary of analysis to assist in the development of resource allocation strategies to meet changing business needs.
  • Respond to internal and external inquiries regarding specific medical procedure coding issues and provide education on proper coding techniques via written and/or telephonic communications.   
  • Develop educational materials for providers identified as outliers and collaborate with Network Management on delivery/communication of information to provider.
  • Maintain documents for tracking audit results, status/outcomes of reviews etc.
  • Participate in or lead special projects based on business area needs requiring independent, sound decision making and broad based understanding of impact on the individual department as well as impact on corporate objectives. 

Hiring Requirements

  • Registered Nurse with valid NC license
  • 5 years clinical experience.  3 of these years must include coding experience.
  • Certified Professional Coder

OR

  • Licensed Practical Nurse with valid NC license
  • 7 years clinical experience.  3 of these years must include coding experience.
  • Certified Professional Coder

Hiring Preferences

  • Understanding of Risk Adjustment methodologies
  • Thorough knowledge and understanding of medical coding with an emphasis on ICD-9 and ICD-10
  • Experience developing educational materials for providers
  • Experience in multiple clinical settings
  • Understanding of medical criteria, medical guidelines, medical policy and NCQA, DOI, Medicare/CMS regulations.
  • Thorough knowledge and understanding of medical terminology.
  • Knowledge of Blue Cross NC benefits plans and operating systems.

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Senior Coding Analyst
Blue Cross and Blue Shield of North Carolina