Clinical Policy Clinical Coder RN II

Job Description

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 position 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.

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.This position works cross-functionally with internal teams to ensure policies are codified, consistently applied, and monitored through reporting and data analysis.

This position 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. 

Qualifications

Education Required:

• Associate's Degree in Nursing

Preferred:

• Bachelor's Degree in Nursing

Experience Required:

• 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 in performing and creating clinical documentation.
• Experience in regulatory compliance for a health plan.Experience with medical coding systems.

Preferred:

• At least 1 year of experience in editing and writing clinical health services policies within a managed care health plan. 

About the Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.