Clinical Policy Clinical Coder Rn Ii

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.