DRG Validation RN — Clinical Claims Auditor

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

Job summary

Molina Healthcare is seeking a Registered Nurse with inpatient claim review experience to verify diagnoses, procedures, revenue codes, and DRG assignments for inpatient and outpatient claims. You will integrate ICD-10 principles and DRG methodologies while ensuring documentation integrity and compliance with payer policies.

The role requires a valid RN license, strong clinical judgment, and the ability to collaborate with coding and analytics teams.

Qualifications

• At least 2 years of inpatient payment integrity medical claim review experience including DRG validation or itemized bill review.
• Active RN license in state of practice with advanced DRG methodologies.
• Familiarity with UHDDS, CMS/Medicaid billing guidelines, and coding clinics.
• Ability to apply clinical judgment to complex claim scenarios.

Responsibilities

• Review inpatient and/or outpatient claims for accuracy of diagnoses, procedures, revenue codes, charges, and DRG assignments.
• Integrate ICD-10 coding principles and DRG methodologies to assess accuracy and alignment with documentation.
• Perform DRG validation by verifying diagnoses, complications, and grouping logic.
• Conduct itemized bill reviews to ensure charges are supported and compliant with standards.
• Develop clear, evidence-based rationales for recommendations and determinations.
• Collaborate with coding, payment integrity analytics, and physician advisors as needed.
• Meet productivity goals and maintain high accuracy in clinical validation and claim reviews.

Skills

Inpatient review

DRG validation

ICD-10 familiarity

MS-DRG/AP-DRG

Nursing license

CMS guidelines

Analytic skills

Communication skills

Education

RN license

Job description

Molina Healthcare is seeking a Registered Nurse with inpatient claim review experience to verify diagnoses, procedures, revenue codes, and DRG assignments for inpatient and outpatient claims. You will integrate ICD-10 principles and DRG methodologies while ensuring documentation integrity and compliance with payer policies.

The role requires a valid RN license, strong clinical judgment, and the ability to collaborate with coding and analytics teams.