The Clinical Policy Clinical Coder RN II is responsible for analyzing, interpreting, and operationalizing medical and utilization management policies to ensure accurate coding, appropriate authorization requirements, compliant claims processing, and effective utilization oversight. This role serves as a key clinical and coding resource, translating medical policy requirements into diagnosis, procedure, and service code logic, including determining which codes require prior authorization.
The position conducts in-depth research and analysis of legislation and regulatory requirements, clinical outcomes, utilization, claims, and financial data to identify utilization trends, fiscal risk, and opportunities for policy enhancement and cost containment. It works cross-functionally with internal teams to ensure policies are codified, consistently applied, and monitored through reporting and data analysis.
This role also collaborates closely with internal stakeholders and external entities to support standardized benefit administration, effective program implementation, and organizational compliance with state, federal, and accreditation requirements.
Education
- Associate's degree in Nursing required
- Bachelor's degree in Nursing preferred
Experience
- At least 8 years of experience in clinical nursing
- At least 3 years of experience with Medi-Cal and Medicare in a managed care environment
- Experience performing and creating clinical documentation
- Experience in regulatory compliance for a health plan
- Experience with medical coding systems
- At least 1 year of experience editing and writing clinical health services policies within a managed care health plan preferred
Location
Los Angeles, California, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$102,183 - $163,492
Remote work allowed
No
Posted
2 weeks ago