Clinical Validation & Payment Integrity Lead

Molina Healthcare; United States; On-site; USD 130,000 - 160,000; Full time

Job summary

Molina Healthcare is seeking a senior leader to manage Clinical Validation Payment Integrity review operations, including DRG validation, itemized bill review, and coding/reimbursement accuracy across programs.

The role requires RN licensure and relevant certifications, with 7+ years in payment integrity and 2+ years in people leadership. Strong analytical skills and cross-functional partnering are essential.

Qualifications

• Active RN license in good standing.
• 7+ years in payment integrity or related healthcare audit operations.
• 2+ years of people leadership or supervisory experience.
• Experience applying clinical documentation, coding, and reimbursement knowledge to determine claim payment accuracy.

Responsibilities

• Oversee DRG validation, itemized bill review, and other payment integrity reviews.
• Monitor workflow, productivity, quality, and turnaround times to ensure defensible outcomes.
• Lead calibration, training, and performance coaching to improve consistency.
• Resolve escalated cases and collaborate with claims, coding, and stakeholders.
• Identify trends and opportunities to improve review workflows and tooling.
• Ensure documentation and determinations are clear and evidence-based.

Skills

Leadership

Analytical thinking

Communication

Time management

Coaching

Education

RN license

CCS/CIC/RHIT/RHIA certifications

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a senior leader to manage Clinical Validation Payment Integrity review operations, including DRG validation, itemized bill review, and coding/reimbursement accuracy across programs.

The role requires RN licensure and relevant certifications, with 7+ years in payment integrity and 2+ years in people leadership. Strong analytical skills and cross-functional partnering are essential.