RN Clinical Validation: DRG, Coding & Claims Review

Molina Healthcare; Northern (KY); Hybrid; USD 36,000 - 77,000; Full time

Job summary

Molina Healthcare is seeking a Nurse reviewer to support inpatient and outpatient clinical claim review activities. You will verify diagnoses, procedures, revenue codes, and reimbursement methods against documentation and guidelines.

The role requires an active RN license, expertise in DRG methodologies, and knowledge of CMS/Medicaid billing guidelines. You will collaborate with teams to ensure accurate coding and compliant billing practices.

Qualifications

• At least 2 years of experience in inpatient payment integrity medical claim review including DRG validation or itemized bill review.
• RN license must be active and unrestricted in state of practice.
• Advanced in DRG methodologies.
• Expertise in UHDDS definitions and CMS/Medicaid guidelines for billing and coding.
• Experience with state, federal, and third‑party regulations and analytical decision making.

Responsibilities

• Review inpatient and outpatient claims to ensure DRG, diagnoses, procedures, revenue codes, and charges reflect the documented care.
• Apply ICD‑10 coding, DRG methodologies, and revenue code logic to ensure accuracy.
• Perform DRG validation including diagnoses, complications, severity, and grouping logic.
• Conduct itemized bill reviews to ensure charges are supported by documentation and compliant with standards.
• Develop evidence‑based rationales for recommendations and ensure outcomes are substantiated.

Skills

DRG validation

ICD-10

MS-DRG/AP-DRG/APR-DRG

CPT/HCPCS

Analytic problem-solving

Communication skills

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Nurse reviewer to support inpatient and outpatient clinical claim review activities. You will verify diagnoses, procedures, revenue codes, and reimbursement methods against documentation and guidelines.

The role requires an active RN license, expertise in DRG methodologies, and knowledge of CMS/Medicaid billing guidelines. You will collaborate with teams to ensure accurate coding and compliant billing practices.