Clinical Validation RN: DRG & Revenue Code Expert

Molina Healthcare; United States; On-site; USD 36,000 - 78,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to review inpatient and outpatient claims, ensuring diagnoses, procedures, revenue codes, and DRG assignments accurately reflect the documented care and billed charges.

You will apply ICD-10 coding principles, DRG methodologies, and payer policies to assess accuracy, produce evidence-based rationales, and collaborate with coding and payment integrity teams to resolve discrepancies and support compliant reimbursement.

Qualifications

• Active RN license in state of practice.
• In-depth knowledge of UHDDS, CMS and Medicaid guidelines.
• Experience with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS.
• Proven ability to apply critical judgment in clinical and coding determinations.
• Strong documentation and communication skills.

Responsibilities

• Review inpatient/outpatient claims for accurate diagnoses, procedures, revenue codes, and DRG assignments.
• Apply ICD-10, DRG methodologies, and billing guidelines to assess accuracy.
• Perform DRG validation and verify diagnoses, complications, and grouping logic.
• Develop written rationales for recommendations based on guidelines and policy.
• Collaborate with coding, analytics, and physician advisors to resolve discrepancies.

Skills

DRG methodologies

Clinical judgment

Analytic problem-solving

Documentation accuracy

Communication skills

Coding knowledge (ICD-10/CPT)

Education

RN license (active)

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Registered Nurse to review inpatient and outpatient claims, ensuring diagnoses, procedures, revenue codes, and DRG assignments accurately reflect the documented care and billed charges.

You will apply ICD-10 coding principles, DRG methodologies, and payer policies to assess accuracy, produce evidence-based rationales, and collaborate with coding and payment integrity teams to resolve discrepancies and support compliant reimbursement.