RN Clinical Validation & DRG Review Specialist

Molina Healthcare; United States; Hybrid; USD 54.000 - 118.000; Vollzeit

Benefits dieser Stelle

Benefits package

EOE employer

Zusammenfassung

Molina Healthcare seeks an RN with inpatient coding, DRG validation, and clinical review experience to support inpatient and outpatient claim reviews. You will verify diagnoses, procedures, revenue codes, and reimbursement methods align with clinical documentation and billing guidelines.

Responsibilities include DRG validation, accuracy checks, and developing written rationales for recommendations, while ensuring compliance with regulatory requirements and Molina payment integrity standards.

Qualifikationen

• 2+ years in inpatient payment integrity review including DRG validation
• RN with active license in state of practice
• Advanced in DRG methodologies and coding guidelines
• Experience with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS
• Ability to apply clinical judgment in documentation review and coding determinations

Aufgaben

• Review inpatient/outpatient claims to ensure DRG, diagnoses, revenue codes and charges reflect documented care
• Apply ICD-10/DRG principles and guidelines during reviews for accuracy
• Perform DRG validation and verify diagnoses and procedures
• Develop evidence-based rationales for recommendations
• Ensure compliance with payer policies and regulatory requirements

Kenntnisse

Inpatient coding

DRG validation

Medical claim review

CPT/HCPCS knowledge

CMS guidelines

UHDDS definitions

Critical thinking

Communication skills

RN licensure

Ausbildung

RN license

Tools

MS Office

EHR systems

Jobbeschreibung

Molina Healthcare seeks an RN with inpatient coding, DRG validation, and clinical review experience to support inpatient and outpatient claim reviews. You will verify diagnoses, procedures, revenue codes, and reimbursement methods align with clinical documentation and billing guidelines.

Responsibilities include DRG validation, accuracy checks, and developing written rationales for recommendations, while ensuring compliance with regulatory requirements and Molina payment integrity standards.