RN Clinical Validation Specialist: DRG & Coding Integrity

Molina Healthcare; United States; On-site; USD 36,000 - 79,000; Full time

Job summary

Molina Healthcare seeks a qualified RN with strong DRG validation and ICD-10 coding expertise to review inpatient and outpatient claims for accuracy and compliance. You will apply DRG methodologies, revenue code logic, and payer policies to ensure proper reimbursement and documentation integrity.

The role requires experience with CMS and state guidelines, analytic skills, and collaboration with cross-functional teams to resolve complex coding discrepancies and improve review processes.

Qualifications

• Active RN license in state of practice (required).
• In-depth knowledge of ICD-10, DRG methodologies, and related guidelines.
• Experience with CMS/Medicaid coding guidelines and AHAs coding clinic.
• Proven ability to apply critical judgment in clinical and coding determinations.

Responsibilities

• Review inpatient and outpatient claims to ensure accuracy of diagnoses, procedures, revenue codes, and DRG assignments.
• Apply DRG validation and coding guidelines to determine payer eligibility and reimbursement.
• Prepare evidence-based rationales for coding determinations and document review outcomes.
• Collaborate with coding, payment integrity analytics, and physician advisors to resolve discrepancies.

Skills

DRG validation

ICD-10 coding

CMS/Medicaid guidelines

Analytical skills

Communication skills

Microsoft Office

Education

RN license (active)

Nursing degree

Coding certifications preferred

Tools

UpToDate

Merck Manual

Job description

Molina Healthcare seeks a qualified RN with strong DRG validation and ICD-10 coding expertise to review inpatient and outpatient claims for accuracy and compliance. You will apply DRG methodologies, revenue code logic, and payer policies to ensure proper reimbursement and documentation integrity.

The role requires experience with CMS and state guidelines, analytic skills, and collaboration with cross-functional teams to resolve complex coding discrepancies and improve review processes.