Manager, DRG Coding & Validation (RN) Remote

Molina Healthcare; Omaha (NE); Remote; USD 85,000 - 120,000; Full time

Job summary

Molina Healthcare is seeking a Manager for DRG Coding & Validation. This remote position requires extensive clinical nursing and coding experience, focusing on reimbursement guidelines and invoicing integrity. The manager will oversee DRG validation processes, conduct audits, and lead a team to ensure accuracy and compliance with healthcare regulations. This is a prime opportunity for professionals skilled in clinical audit practices and coding standards.

Qualifications

• 7+ years of Clinical Nursing experience.
• 5+ years in claims auditing, ideally in DRG/Clinical Validation.
• Active RN license and CCS or CIC certification required.

Responsibilities

• Develop and implement the DRG validation program.
• Ensure timely claim settlement and quality review for ICD-10-CM codes.
• Manage medical claim review nurses.

Skills

ICD-10 Coding Principles

Clinical Guidelines

Claims Auditing

Team Management

Regulatory Compliance

Education

Bachelor's Degree in Nursing or Health-Related Field

Job description

Manager, DRG Coding & Validation (RN) Remote

Join to apply for the Manager, DRG Coding & Validation (RN) Remote role at Molina Healthcare

Job Summary

The Manager, Clinical DRG Coding & Validation must have extensive experience in facility-based nursing and/or inpatient coding, with a strong understanding of reimbursement guidelines related to MS-DRG, AP-DRG, and APR-DRG payment systems. This role involves developing and implementing the DRG validation program, auditing inpatient medical records, and ensuring accurate claims payment for payment integrity. The manager will perform clinical reviews to evaluate coding and DRG assignment accuracy.

Responsibilities include ensuring timely claim settlement, maintaining quality review standards for ICD-10-CM and CPT codes, and accurate DRG or APC assignment. Prior management and DRG validation experience are highly preferred.

Work hours: Monday - Friday: 7:00 AM - 5:00 PM EST

Position: Remote

Licensure: Unrestricted RN license required

Knowledge/Skills:

• Develop and implement the DRG validation program, including tools, workflows, training, audits, and production management.
• Apply advanced ICD-10 coding principles, clinical guidelines, and perform independent medical audits.
• Proficient in Molina's proprietary auditing systems for decision-making and team training.
• Manage medical claim review nurses, ensuring operational goals and quality standards are met.
• Provide ongoing training and feedback to team members, coordinate training programs, and develop work plans.
• Influence and engage team members and peers to achieve results remotely and onsite.
• Lead and develop staff, identify process improvements, and maintain Job Aids.
• Escalate claims issues to relevant leaders and ensure adherence to coding guidelines, including NCCI and CMS regulations.
• Support the development of auditing rules to meet regulatory mandates.
• Perform other duties as assigned.

Qualifications:

Education: Bachelor's Degree in Nursing or a Health-Related Field

Experience:

• 7+ years of Clinical Nursing experience
• 5+ years in claims auditing, quality assurance, or recovery auditing, ideally in DRG/Clinical Validation
• 3+ years of Utilization Review or Medical Claims Review experience
• 3+ years of managerial experience
• Extensive knowledge of ICD-10, MS-DRG, AP-DRG, and APR-DRG systems, billing/payment systems, and coding terminology

Licenses/Certifications: Active RN license and CCS or CIC certification in good standing

Preferred: Master's Degree or equivalent; additional certifications such as RHIT, RHIA, CPC

To apply, current Molina employees should use the intranet. Molina Healthcare offers competitive benefits. This position is an equal opportunity employer.