Remote DRG & Coding Validation Specialist

Molina Healthcare; United States; Remote; USD 36,000 - 77,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a registered nurse to support inpatient and outpatient clinical claim review activities. You will verify diagnoses, procedures, revenue codes, and DRG assignments to ensure accurate reimbursement and compliance with coding guidelines.

The role involves independent review, evidence-based rationale, and collaboration with related teams. Ideal candidates have RN licensure, DRG expertise, and familiarity with ICD-10, CPT/HCPCS, and UHDDS.

Qualifications

• Active RN license in state of practice.
• Strong knowledge of DRG methodologies and ICD-10 coding principles.
• Experience with inpatient payment integrity claim review and coding guidelines.

Responsibilities

• Review inpatient/outpatient claims for diagnoses, procedures, revenue codes, DRG and charges.
• Apply DRG validation and DRG grouping logic with clinical documentation support.
• Identify discrepancies impacting reimbursement and provide evidence-based rationales.
• Collaborate with coding, analytics, and physician advisors to resolve complex cases.
• Ensure compliance with payer policies and regulatory requirements.

Skills

Analytic skills

Communication skills

MS Office proficiency

Education

RN license

DRG methodologies

HIM/coding certifications (preferred)

Tools

UpToDate/Merck Manual

Coding software/tools

Job description

Molina Healthcare is seeking a registered nurse to support inpatient and outpatient clinical claim review activities. You will verify diagnoses, procedures, revenue codes, and DRG assignments to ensure accurate reimbursement and compliance with coding guidelines.

The role involves independent review, evidence-based rationale, and collaboration with related teams. Ideal candidates have RN licensure, DRG expertise, and familiarity with ICD-10, CPT/HCPCS, and UHDDS.