RN: Clinical Validation & DRG Reviewer

Molina Healthcare; United States; On-site; USD 85,000 - 120,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare is seeking an experienced RN to support inpatient and outpatient clinical claim review activities. You will verify coded diagnoses, procedures, revenue codes, and DRG assignments, ensuring reimbursement reflects documentation and guidelines.

You will collaborate with coding, payment integrity analytics, SIU, and physician advisors to resolve discrepancies, develop evidence-based rationales, and ensure compliance with regulatory requirements.

Qualifications

• RN license active and unrestricted in practice state.
• 2+ years in inpatient payment integrity claim review with DRG validation or itemized bill review.
• Knowledge of UHDDS definitions and CMS/Medicaid coding guidelines.
• Experience with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS.
• Proven ability to apply critical judgment in coding determinations.
• Strong written and verbal communication skills.

Responsibilities

• Reviews inpatient/outpatient claims to ensure DRG, diagnoses, procedures, and revenue codes reflect documented services.
• Applies ICD-10, DRG methodologies, and revenue code logic for accuracy.
• Performs DRG validation by verifying diagnoses, complications, severity, and grouping logic.
• Conducts itemized bill reviews to ensure charges align with documentation and standards.
• Drafts evidence-based rationales supporting recommendations and determinations.
• Ensures outcomes comply with guidelines, payer policy, and regulations.
• Collaborates with coding, payment integrity analytics, SIU, and physicians to resolve discrepancies.
• Provides SME on DRG validation and documentation integrity when needed.
• Meets productivity and accuracy targets set by leadership.
• Participates in quality checks, training, and process improvement initiatives.

Skills

DRG validation

Inpatient claim review

Clinical coding guidelines

Analytical thinking

Communication skills

Problem solving

Education

RN license (active)

CCS / RHIA / RHIT / CIC / CDIP (preferred)

Other HIM/coding certifications

Tools

UpToDate

Merck Manual

Job description

Molina Healthcare is seeking an experienced RN to support inpatient and outpatient clinical claim review activities. You will verify coded diagnoses, procedures, revenue codes, and DRG assignments, ensuring reimbursement reflects documentation and guidelines.

You will collaborate with coding, payment integrity analytics, SIU, and physician advisors to resolve discrepancies, develop evidence-based rationales, and ensure compliance with regulatory requirements.