Senior Clinical Validation Lead

Molina Healthcare; Northern (KY); Hybrid; USD 60,000 - 130,000; Full time

Job summary

Molina Healthcare seeks a lead clinical validation reviewer to support medical necessity determinations and payment integrity. You will work with the Manager on workflow coordination, calibration, and tool development to ensure timely and accurate review outcomes.

Ideal candidates have 3+ years in payment integrity review, strong ICD-10 and DRG knowledge, and ability to guide staff in coding accuracy and reimbursement impact.

Qualifications

• RN license active and unrestricted in practice state.
• 3+ years in payment integrity medical claim review or equivalent.
• Experience with ICD-10, MS-DRG, AP-DRG, APR-DRG coding and guidelines.
• Ability to provide lead-level guidance and training to staff.

Responsibilities

• Assist Manager with workflow coordination and case routing.
• Provide lead-level clinical, coding, and reimbursement guidance.
• Perform advanced reviews to verify diagnoses, procedures, and charges reflect documentation and policies.
• Assess documentation for accuracy, acuity, and reimbursement impact.
• Apply coding guidelines and regulatory requirements across reviews.
• Identify and escalate unsupported or incorrect coding or charges.
• Develop rationales for findings and support calibration discussions.
• Support onboarding, training, and development of review tools and templates.
• Identify trends and opportunities and escalate to Manager.

Skills

RN license

Payment integrity

DRG methodologies

ICD-10 coding

Analytical thinking

Communication skills

Microsoft Office

Job description

Molina Healthcare seeks a lead clinical validation reviewer to support medical necessity determinations and payment integrity. You will work with the Manager on workflow coordination, calibration, and tool development to ensure timely and accurate review outcomes.

Ideal candidates have 3+ years in payment integrity review, strong ICD-10 and DRG knowledge, and ability to guide staff in coding accuracy and reimbursement impact.