Lead Clinical Validation RN – Payment Integrity

Molina Healthcare; United States; On-site; USD 60,000 - 130,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a lead clinical validation reviewer to support payment integrity and DRG validation. You will assist the Manager with workflow coordination, case routing, calibration, and the development of tools to ensure accurate, defensible review outcomes.

The role requires an active RN license and at least 3 years in payment integrity claim review, with expertise in ICD-10, DRG methodologies, CPT/HCPCS, and regulatory guidelines.

Qualifications

• Active RN license in the state of practice.
• Minimum of 3 years of payment integrity medical claim review experience including DRG validation and coding/reimbursement guidance.
• Ability to lead, train, calibrate, and support clinical review staff.

Responsibilities

• Assist Manager with day-to-day clinical validation review operations, workflow coordination, case routing, escalation of complex issues.
• Provide lead-level guidance on clinical validation, coding, reimbursement, and payment integrity for claims reviews.
• Ensure accuracy of coded diagnoses, procedures, revenue codes, and reimbursement methodologies through review and documentation.

Education

RN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a lead clinical validation reviewer to support payment integrity and DRG validation. You will assist the Manager with workflow coordination, case routing, calibration, and the development of tools to ensure accurate, defensible review outcomes.

The role requires an active RN license and at least 3 years in payment integrity claim review, with expertise in ICD-10, DRG methodologies, CPT/HCPCS, and regulatory guidelines.