Clinical Validation RN — DRG & Coding Specialist

Molina Healthcare; United States; On-site; USD 36,000 - 77,000; Full time

Benefits offered by this job

Competitive benefits

EOE employer

Job summary

Molina Healthcare is seeking a qualified RN for inpatient/outpatient claim review to verify diagnoses, procedures, revenue codes, and DRG assignments against documentation. You will apply ICD-10 and DRG methodologies, assess accuracy and adherence to payer policies, and produce evidence-based rationales for determinations.

The role requires an active RN license, 2+ years in payment integrity review, and strong analytical, communication, and time-management skills.

Qualifications

• At least 2 years of inpatient payment integrity medical claim review including DRG validation or itemized bill review.
• Active RN license in state of practice.
• Advanced in DRG methodologies.
• Expertise in UHDDS definitions and CMS/Medicaid guidelines.
• Familiarity with UpToDate or similar clinical decision tools.
• Ability to apply clinical criteria to support code assignments.
• Strong judgment, problem-solving and decision-making.
• Solid knowledge of regulations and payer policies; strong communication.
• Analytical thinking, time management and attention to detail.
• Proficient in Microsoft Office and related software.

Responsibilities

• Review inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, and DRG assignments reflect documented care.
• Integrate ICD-10, DRG methodologies, and guidelines when reviewing claims for accuracy and alignment with documentation.
• Validate DRGs by verifying diagnoses, complications, and grouping logic.
• Conduct itemized bill reviews to confirm charges are supported by documentation and compliant with standards.
• Develop written rationales supporting recommendations and determinations.
• Substantiate outcomes using clinical indicators, guidelines, and payer requirements.
• Perform review work independently with sound clinical judgment on complex cases.
• Apply federal/state regulations and Molina payment integrity standards during reviews.
• Ensure compliance with DRG and itemized bill criteria and reimbursement methodologies.
• Collaborate with coding, analytics, SIU, and physician advisors to resolve discrepancies.
• Share SME knowledge on DRG validation and documentation integrity with internal partners.
• Meet productivity and quality targets for clinical validation and claim review.
• Participate in quality checks, calibration sessions, and ongoing training.

Skills

DRG validation

ICD-10 proficiency

MS-DRG knowledge

CPT / HCPCS

Critical thinking

Communication

Time management

Detail oriented

Microsoft Office

Education

RN license

Job description

Molina Healthcare is seeking a qualified RN for inpatient/outpatient claim review to verify diagnoses, procedures, revenue codes, and DRG assignments against documentation. You will apply ICD-10 and DRG methodologies, assess accuracy and adherence to payer policies, and produce evidence-based rationales for determinations.

The role requires an active RN license, 2+ years in payment integrity review, and strong analytical, communication, and time-management skills.