Remote Clinical Validation Specialist: DRG & Coding Review

Molina Healthcare; United States; Remote; USD 36,000 - 79,000; Full time

Job summary

Molina Healthcare is seeking a registered nurse with inpatient claim review experience to ensure diagnoses, procedures, revenue codes, and DRG assignments accurately reflect the documented care and billed charges.

You will apply ICD-10, DRG and revenue code guidelines, review complex scenarios, and collaborate with payment integrity teams to uphold documentation integrity and compliant reimbursement.

Qualifications

• Minimum 2 years of inpatient payment integrity claim review experience, with DRG validation or itemized bill review.
• Active RN license in state of practice.
• Advanced knowledge of DRG methodologies and UHDDS definitions.
• Familiarity with ICD-10, MS-DRG, CPT, HCPCS coding guidelines.
• Strong analytic, problem-solving, and decision-making skills.
• Excellent verbal and written communication.

Responsibilities

• Reviews inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, itemized charges, and DRG assignments reflect the documented medical condition and services.
• Integrates coding principles and guidelines when reviewing claims for accuracy and alignment with documentation.
• Performs DRG validation and verifies diagnoses, complications, and grouping logic.
• Conducts itemized bill reviews to confirm charges are supported by documentation and compliant with standards.
• Develops written rationales supporting coding recommendations and determinations.

Skills

Analytic thinking

Problem-solving

Decision-making

Verbal and written communication

Attention to detail

Time management

Education

RN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a registered nurse with inpatient claim review experience to ensure diagnoses, procedures, revenue codes, and DRG assignments accurately reflect the documented care and billed charges.

You will apply ICD-10, DRG and revenue code guidelines, review complex scenarios, and collaborate with payment integrity teams to uphold documentation integrity and compliant reimbursement.