RN Clinical Validation Reviewer: DRG & Coding Expert

Molina Healthcare; Northern (KY); Hybrid; USD 36,000 - 78,000; Full time

Job summary

Molina Healthcare seeks a Registered Nurse to provide support for inpatient and outpatient clinical claim review activities. You will verify that diagnoses, procedures, revenue codes, and DRG assignments accurately reflect the member's care and billed charges.

Apply ICD-10 coding principles, DRG methodologies, and payer policies to ensure documentation integrity and compliance with CMS/Medicaid guidelines. Collaboration with coding and analytics teams is expected.

Qualifications

• Active RN license in state of practice
• In-depth knowledge of ICD-10, DRG, CPT, HCPCS coding systems
• Familiarity with UHDDS definitions and inpatient coding guidelines
• Experience with CMS and Medicaid billing/coding guidelines

Responsibilities

• Reviews inpatient/outpatient claims to ensure diagnoses, procedures, revenue codes, charges, and DRG assignments reflect services provided
• Applies ICD-10 coding principles and DRG methodologies to assess accuracy and alignment with documentation
• Performs DRG validation by verifying diagnoses, complications, procedures, severity, and grouping logic
• Reviews itemized bills to confirm charges are supported by clinical documentation and compliant with standards
• Develops clear, evidence-based rationales for coding recommendations and determinations
• Ensures all review outcomes are substantiated by guidelines, policies, and regulatory requirements

Skills

RN license

DRG methodologies

ICD-10 & coding guidelines

CMS/Medicaid guidelines

Analytical skills

Communication skills

Microsoft Office

Problem solving

Education

Active RN license

Job description

Molina Healthcare seeks a Registered Nurse to provide support for inpatient and outpatient clinical claim review activities. You will verify that diagnoses, procedures, revenue codes, and DRG assignments accurately reflect the member's care and billed charges.

Apply ICD-10 coding principles, DRG methodologies, and payer policies to ensure documentation integrity and compliance with CMS/Medicaid guidelines. Collaboration with coding and analytics teams is expected.