Clinical Policy Clinical Coder RN II

L.A. Care Health Plan, the nation's largest publicly operated health plan, is seeking a Clinical Policy Clinical Coder RN II located in Los Angeles, CA. The role involves analyzing, interpreting, and operationalizing medical and utilization management policies to ensure accurate coding, proper authorization requirements, compliant claims processing, and effective utilization oversight.

Key responsibilities include translating clinical policies into codified claims rules, developing and revising clinical policies and utilization management criteria, assessing claims impact of policy changes, validating claims configurations, monitoring claims activity, leading workgroups and committees, managing projects, supporting claims processing accuracy, investigating coding and authorization issues, and analyzing utilization data to recommend policy refinements.

This position requires strong collaboration with internal teams and external entities to standardize benefit administration, ensure compliance with regulatory requirements, and enhance policy effectiveness.

Education requirement: Associate's Degree in Nursing (Bachelor's preferred). Experience: At least 8 years in Clinical Nursing and 3 years with Medi-Cal and Medicare in managed care. Skills include working knowledge of clinical policies and medical coding systems (ICD-10-CM, CPT, HCPCS), research abilities, analytical and problem-solving skills, and proficiency in Microsoft Office.

Licenses: Active and unrestricted California Registered Nurse (RN) license required; Certified Professional Coder (CPC) preferred.

Benefits include paid time off, tuition reimbursement, retirement plans, medical/dental/vision coverage, wellness programs, and volunteer time off.

The salary range is $102,183 to $163,492 annually.