RN Clinical Validation & DRG Coding Specialist

Molina Talent Acquisition; United States; On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Benefits package

Job summary

Molina Healthcare is seeking an experienced RN to support inpatient and outpatient clinical claim reviews, validating diagnoses, procedures, revenue codes, and DRG assignments against documentation and payer guidelines.

The role emphasizes accuracy, adherence to CMS/official coding guidelines, and collaboration with coding teams to ensure compliant, cost-effective care. Strong analytical and communication skills are required.

Qualifications

• RN license active and unrestricted in state of practice.
• In-depth knowledge of ICD-10, DRG methodologies, and billing guidelines.
• Experience with UHDDS, CMS/Medicaid guidelines, and coding clinics.

Responsibilities

• Review inpatient/outpatient claims to verify diagnoses, procedures, revenue codes, and DRG assignments reflect documented care.
• Apply ICD-10 and DRG methodologies and payer policies to ensure accuracy and compliance.
• Produce clear rationales for coding decisions with supporting documentation.
• Collaborate with coding, analytics, and physician advisors to resolve discrepancies.

Skills

Inpatient claim review

DRG validation

ICD-10 familiarity

Analytical skills

Education

RN license

Tools

MS Office

UpToDate

Merck Manual

Job description

Molina Healthcare is seeking an experienced RN to support inpatient and outpatient clinical claim reviews, validating diagnoses, procedures, revenue codes, and DRG assignments against documentation and payer guidelines.

The role emphasizes accuracy, adherence to CMS/official coding guidelines, and collaboration with coding teams to ensure compliant, cost-effective care. Strong analytical and communication skills are required.