Clinical Validation Reviewer – DRG & Coding Expert

Molina Healthcare; United States; On-site; USD 54,000 - 118,000; Full time

Job summary

Molina Healthcare is seeking a qualified RN for inpatient and outpatient clinical claim review to verify diagnoses, procedures, and DRG assignments against documentation and billing guidelines. The role requires applying ICD-10, DRG methodologies, and revenue code logic with strong analytical and communication skills.

Responsibilities include independent reviews, development of evidence-based rationales, and collaboration with coding, analytics, and physician teams to ensure accurate

Qualifications

• At least 2 years of inpatient payment integrity claim review experience with DRG validation or itemized bill review.
• Active RN license in state of practice.
• Proficiency in UHDDS definitions and CMS/Medicaid coding guidelines.
• Knowledge of ICD-10, DRG methodologies, CPT/HCPCS coding.
• Strong analytical, problem-solving, and decision-making skills.
• Excellent written and verbal communication.
• Proficiency with Microsoft Office.

Responsibilities

• Reviews inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, charges and DRG assignments reflect services provided.
• Integrates ICD-10 coding principles, DRG methodologies, revenue code logic and guidelines when reviewing claims.
• Performs DRG validation by verifying diagnoses, complications, severity, and grouping.
• Performs itemized bill reviews to confirm charges are supported by documentation and compliant with standards.
• Develops evidence-based rationales supporting coding and DRG recommendations.
• Substantiates review outcomes using coding guidelines, payer policies and regulatory requirements.
• Executes reviews independently with clinical judgment and specialized expertise.
• Applies federal/state regulations, coding guidelines, payer policies and Molina standards.
• Collaborates with coding, analytics, SIU and physician advisors to resolve discrepancies.

Skills

Inpatient payment integrity

DRG validation

ICD-10 knowledge

CPT/HCPCS knowledge

Analytical thinking

Critical thinking

Communication skills

Time management

Problem solving

Attention to detail

Education

RN license (active)

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a qualified RN for inpatient and outpatient clinical claim review to verify diagnoses, procedures, and DRG assignments against documentation and billing guidelines. The role requires applying ICD-10, DRG methodologies, and revenue code logic with strong analytical and communication skills.

Responsibilities include independent reviews, development of evidence-based rationales, and collaboration with coding, analytics, and physician teams to ensure accurate