Senior Manager, Clinical Validation & Payment Integrity

Molina Healthcare; Northern (KY); Hybrid; USD 66,000 - 143,000; Full time

Benefits offered by this job

Competitive benefits

Equal Opportunity Employer

Job summary

Molina Healthcare is seeking a seasoned RN leader to oversee Clinical Validation Payment Integrity review programs, including DRG validation, itemized bill review, and coding accuracy. You will manage day-to-day production, quality, calibration, and workflow improvements across claims and provider-facing teams to ensure defensible payment outcomes.

Responsibilities include supervising reviews, enforcing documentation standards, and collaborating with claims, coding, SIU, and health plan partners

Qualifications

• Active RN license in practice state.
• 7+ years in payment integrity or related healthcare audit operations.
• Leadership or supervisory experience in healthcare environments.
• Knowledge of ICD-10-CM/PCS, DRG and billing guidelines.

Responsibilities

• Oversee DRG validation, itemized bill review, and coding accuracy reviews.
• Lead calibration, quality reviews, and performance metrics.
• Collaborate with claims, coding, SIU, and health plan partners to resolve issues.
• Ensure documentation and determinations are defensible and compliant.

Skills

Registered Nurse (RN)

Leadership experience

Analytical skills

Microsoft Office

Education

RN License

CCS / CIC / RHIT / RHIA certifications

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a seasoned RN leader to oversee Clinical Validation Payment Integrity review programs, including DRG validation, itemized bill review, and coding accuracy. You will manage day-to-day production, quality, calibration, and workflow improvements across claims and provider-facing teams to ensure defensible payment outcomes.

Responsibilities include supervising reviews, enforcing documentation standards, and collaborating with claims, coding, SIU, and health plan partners