Clinical Policy Clinical Coder RN II

L.A. Care Health Plan•Los Angeles, CA

About The Position

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.

Requirements

Associate's Degree in Nursing
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.
Proficient with clinical policy through skills in literature searching and clinical research analysis based on the best available evidence.
Working knowledge of clinical policies.
Working knowledge of CPT/HCPC codes and claims.
Ability to translate regulatory requirements into auditable tools.
Ability to perform independent research on complex medical topics.
Excellent verbal and written communication skills.
Strong analytical, problem solving, and team building skills.
Ability to work independently with strong self-direction.
Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools.
Ability to work effectively with diverse teams in cross-functional work groups.
Ability to multitask, re-prioritize tasking, and streamline day-to-day operations.
Ability to identify discrepancies, assess risk, and recommend actionable solutions.
Knowledge of medical coding systems, including ICD-10-CM, CPT, and HCPCS, and their application in authorization and claims environments.
Strong organizational and time-management skills.
Registered Nurse (RN) - Active, current and unrestricted California License

Nice To Haves

Bachelor's Degree in Nursing
At least 1 year of experience in editing and writing clinical health services policies within a managed care health plan.
Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence.
Proficient in claims configuration, including claims adjudication workflows, configuration of claims edits and rules, and the translation of clinical and utilization management policies into system-based claims logic to support accurate, compliant payment outcomes.
Understanding of the managed care industry and market conditions.
Certified Professional Coder (CPC)

Responsibilities

Translate approved clinical policies and utilization management criteria into clear, codified claims rules and system logic to support accurate claims adjudication.
Develop, revise, and recommend clinical policies and internal utilization management criteria when standard clinical guidelines are insufficient to support appropriate decision-making based on codified claim rules.
Assess the downstream claims impact of new or revised clinical policies prior to implementation and recommend configuration updates to mitigate operational or financial risk.
Participate in validation of claims configuration changes to ensure policies are applied correctly and consistently across all lines of business.
Monitor post-implementation claims activity to identify configuration issues, unintended denials, or payment discrepancies related to clinical policy application. Support remediation of claims configuration defects by identifying root causes and coordinating corrective actions with internal teams.
Participate in and lead specialty and cross-functional workgroups and committees focused on healthcare services clinical policies, utilization management processes, strategic initiatives, policy governance, operational alignment, and continuous improvement efforts.
Ensure timely dissemination of accurate and consistent policies and procedures across departments.
Promote collaboration, engagement, and a positive work environment while supporting departmental initiatives and team-based activities.
Manage assigned projects from concept through implementation, ensuring timelines, quality standards, and deliverables are met.
Analyze and interpret medical and utilization management policies to identify applicable diagnosis, procedure, and service codes and determine authorization, pre-payment, or post-payment review requirements.
Define and maintain code lists that require prior authorization or other utilization management controls based on clinical evidence, regulatory guidance, utilization trends, and financial risk.
Collaborate with internal teams to ensure authorization requirements and coding logic are accurately configured in authorization and claims systems based on authorization matrix requirements.
Support accurate claims processing by validating codified authorization and policy requirements are correctly applied and aligned with approved medical policies.
Provide clinical and coding recommendations to support the development, revision, and implementation of new or updated medical and utilization management policies.
Investigate and resolve coding and authorization related issues, including claim denials, coding edits, authorization discrepancies, and policy interpretation questions.
Review and assess claims edits, authorization matrixes, and coding rules to identify root causes of errors or inconsistencies and recommend corrective actions.
Ensure coding, authorization requirements, and claims-related guidance align with medical necessity criteria, benefit structures, and applicable state, federal, and regulatory requirements.
Develop, review, and maintain reporting related to authorization required codes, approval and denial rates, utilization patterns, claims payment outcomes, and policy effectiveness.
Prepare reports, summaries, and presentations and communicate findings, recommendations, and action plans to internal and external stakeholders.
Analyze claims, authorization, and utilization data to identify trends, measure policy impact, and recommend opportunities for policy refinement, cost containment, or reduction of administrative burden.
Monitor post-implementation performance of authorization-required codes and recommend additions, removals, or modifications to authorization requirements based on regulatory thresholds and utilization outcomes.
Perform other duties as assigned.