Certified Coding Specialist

Overview CalOptima Health is seeking a highly motivated Certified Coding Specialist to join our team. The Certified Coding Specialist will assist the Manager Coding Quality in implementing coding standards for the organization, including researching relevant regulations, serving as a resource for other departments, and reviewing and recommending changes to systems, policies, or procedures to ensure current and appropriate coding guidelines are maintained. The incumbent will review the appropriateness of codes billed when reviewing medical records related to provider disputes and appeals. Additionally, the incumbent will respond to questions submitted to the coding support mailbox and provide code guidance based on Medicare, Medi-Cal and national standards of billing protocol. Position Information Department: Coding Initiatives Salary Grade: 306 - $58,205 - $90,217 ($27.98 - $43.3736) Work Arrangement: Full Telework This position is eligible for telework in California. Duties & Responsibilities Program Support (approximately 95%) Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Supports the manager in ensuring current coding methodology and modifier rules are applied to appropriate reimbursement and ensures the organization is following Medicare and Medi-Cal protocol for payment of claims. Maintains and monitors code listing updates for ICD-10-CM/PCS, CPT and HCPCS as needed for all lines of business. Assists the manager with identifying questionable billing practices based on coding protocol. Responds with advice and instructions to any inquiries related to coding appropriateness and review of documentation provided. Assists the Contracting department with contractual billing requirements based on coding standards by identifying applicable procedure codes according to provider specialty. Presents at provider workshops and assists with provider training on regulations for appropriate coding of medical charts and documentation required to support proper claims submission. Assists other departments regarding evaluation of medical records, procedures or diagnosis code questions; identifies ambiguous or non-specific medical documentation regarding coding protocols related to provider disputes, appeals and coding audits on submitted claims. Stays current on official health care regulations, including reimbursement and documentation requirements related to professional claims billing. Ensures compliance with the standards of ethical coding as set forth by AHIMA and adheres to official guidelines. Other (5%) Completes other projects and duties as assigned. Minimum Qualifications Bachelor's degree in public health, health services or related field plus 3 years of coding experience with an emphasis on Medicare and Medi-Cal requirements in a managed care environment required; an equivalent combination of education and experience may qualify. 1 year of experience working with ICD-10-CM/PCS, CPT and HCPCS coding, medical terminology, human anatomy/physiology and regulatory requirements required. Preferred Qualifications Experience working with MS-DRG, APR-DRG and Medi-Cal coding assignments as well as Medi-Cal chart auditing. Required Licensure / Certifications Current Certified Coding Specialist (CCS), Certified Coding Specialist Physician-based (CCS-P) or Certified Professional Coder (CPC) Certification by AHIMA or AAPC is required. Knowledge & Abilities Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. Work independently and exercise sound judgment. Communicate clearly and concisely, both orally and in writing. Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem-solve and possess project management skills. Work in a fast-paced environment and in an efficient manner. Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi-program teams and external committees/coalitions. Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Physical Requirements Ability to visually read information from computer screens, forms and other printed materials and information. Ability to speak (enunciate) clearly in conversation and general communication. Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions. Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting. Lifting and moving objects, patients and/or equipment 10 to 25 pounds Work Environment Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. There are no harmful environmental conditions present for this job. The noise level in this work environment is usually moderate. About CalOptima Health CalOptima Health is the largest health plan in Orange County, serving one in four residents. Our motto "Better. Together." guides our mission to serve members with excellence, dignity and respect. We are a public agency with a culture that promotes diversity and inclusion, where employees are valued for their ideas and perspectives. CalOptima Health is recognized as a great place to work. Benefits We offer a comprehensive benefits package, including CalPERS retirement, health, dental and vision insurance options, paid time off, flexible scheduling, telework options where applicable, and a wellness program. CalOptima Health also contributes to retirement programs and offers 457(b) options. See the 2025 CalOptima Health Benefits Guide for details. Application Information Applications accepted on a continuous basis until qualified applicants are exhausted. First review deadline: August 17, 2025 at 9:00 PM (PST). Apply early; applications after the first review may not be considered. Recruitment may close without notice after first review. Selection may include skills assessment, phone screen and interview. Background check and post-offer pre-employment medical examination may be required. Internal CalOptima Health applicants apply through InfoNet. Communications will be sent via the email listed on your application. Check spam and candidate portal for status updates. Reasonable accommodations are available for qualified individuals with a disability or disabled veteran. Contact information provided in listing. To apply, please visit: Equal Opportunity CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. We prohibit unlawful discrimination based on race, religion, color, national origin, disability, age, sex, gender identity, and other protected characteristics. We also provide reasonable accommodations for qualified individuals with disabilities. #J-18808-Ljbffr CalOptima