Manager, Clinical Validation & Payment Integrity

Molina Healthcare; United States; On-site; USD 66,000 - 143,000; Full time

Job summary

Molina Healthcare is seeking an experienced leader to manage Clinical Validation Payment Integrity review operations. The role focuses on DRG validation, itemized bill review, revenue code validation, and clinical documentation review to ensure accurate, timely, and defensible claim outcomes.

Eastern or Central Time zones preferred. Requires active RN license and CCS/CIC/RHIT/RHIA certification, plus 7+ years in payment integrity and 2+ years in people leadership.

Qualifications

• Active RN license in state of practice.
• CCS, CIC, RHIT, or RHIA certification required or equivalent.
• Minimum 7 years in payment integrity, medical claim review, or related healthcare audit operations.
• At least 2 years in people leadership or operational management.

Responsibilities

• Oversee DRG validation, itemized bill review, revenue code and charge validation, and clinical documentation review.
• Ensure compliance with clinical, coding, billing, and regulatory requirements.
• Lead calibration, training, and performance metrics; manage escalations and workflow efficiency.
• Collaborate with claims, coding, SIU, physician advisors, and health plan partners to resolve issues.

Skills

Analytical skills

Leadership

Communication

Education

RN license

CCS/CIC/RHIT/RHIA certification

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an experienced leader to manage Clinical Validation Payment Integrity review operations. The role focuses on DRG validation, itemized bill review, revenue code validation, and clinical documentation review to ensure accurate, timely, and defensible claim outcomes.

Eastern or Central Time zones preferred. Requires active RN license and CCS/CIC/RHIT/RHIA certification, plus 7+ years in payment integrity and 2+ years in people leadership.