Molina Healthcare

Remote DRG Clinical Validation Reviewer (Coding RN)

Molina Healthcare • $80K — $100K *
Long Beach, CA 90802In-Person
Healthcare
Less than 5 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • Active and unrestricted RN license in state of practice
  • Minimum 2 years of experience in inpatient payment integrity claim review
  • Expert in DRG methodologies (MS & APR)
  • Knowledge of UHDDS, Inpatient Coding Guidelines, CMS, and Medicaid guidelines
  • Proficient in evidence-based clinical decision support tools
  • Ability to apply critical judgment in clinical and coding determinations
  • Strong organizational, analytical, and decision-making skills
  • Effective verbal and written communication skills

Responsibilities

  • Review inpatient and outpatient claims for clinical accuracy
  • Integrate ICD-10, DRG methodologies, and clinical guidelines in claims review
  • Perform DRG validation checks on diagnoses and procedures
  • Conduct itemized bill reviews for documentation compliance
  • Identify inaccuracies and unsupported coding in claims
  • Develop evidence-based rationales for coding recommendations
  • Collaborate with internal teams to resolve documentation discrepancies

Benefits

  • Comprehensive health insurance options
  • 401(k) retirement plan
  • Paid time off and holiday benefits
  • Professional development and training programs
  • Employee assistance program for mental health support
Full Job Description
Job Description

Job Description

Job Summary

Performs focused clinical reviews of inpatient and outpatient claims to verify that coded diagnoses, procedures, revenue codes, and corresponding reimbursement methodologies accurately reflect the patient's documented clinical condition, services rendered, and billed charges. Assesses medical records for clinical accuracy, acuity alignment, and documentation integrity. Identifies inconsistencies that impact reimbursement such as unsupported diagnoses, incorrect procedure coding, or inaccurate revenue code assignment and determines whether billed services meet coding and billing guidelines, payer policy, and regulatory requirements.

Job Duties
  • Reviews inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, itemized charges, and Diagnostic Related Groups (DRG) assignments accurately reflect the documented clinical condition and services provided.
  • Integrates ICD-10 coding principles, DRG methodologies, revenue code logic, and evidence-based clinical guidelines when reviewing claims for accuracy, appropriateness, and alignment with documentation.
  • Performs DRG validation reviews by verifying principal and secondary diagnoses, complications/comorbidities, procedure coding, severity level, and correct grouping logic.
  • Conducts itemized bill reviews to confirm that charges are supported by clinical documentation, compliant with billing standards, and appropriate for the level of care delivered.
  • Identifies unsupported, inaccurate, or inappropriate coding or billing elements such as unsubstantiated diagnoses, incorrect procedures, or incorrect revenue code usage.
  • Develops clear, evidence-based written rationales supporting diagnosis, procedure, revenue code, or DRG recommendations and determinations.
  • Substantiates all review outcomes using clinical indicators, documentation, coding guidelines, payer policy, and regulatory requirements.
  • Performs review work independently, applying sound clinical judgment and specialized expertise to evaluate complex claim scenarios.
  • Applies applicable federal/state regulations, official coding guidelines, payer policies, and Molina Payment Integrity standards during all reviews.
  • Ensures compliance with DRG and itemized bill review criteria, clinical validation rules, and reimbursement methodologies.
  • Collaborates with coding, payment integrity analytics, SIU, and physician advisors to clarify complex clinical documentation, coding discrepancies, or reimbursement determinations.
  • Provides subject-matter expertise on DRG validation, revenue code accuracy, itemized bill review, and documentation integrity to internal partners as needed.
  • Meets or exceeds established productivity goals set by Payment Integrity leadership for clinical validation and claim review activities.
  • Achieves the required accuracy and quality standards for review, diagnosis/procedure validation, and/or itemized bill reviews.
  • Participates in quality checks, calibration sessions, and ongoing training to maintain consistency and strengthen review competency.
  • Completes special projects and additional review assignments as delegated by leadership.
  • Identifies patterns and trends in documentation, coding, or billing that may require internal escalation, provider education, or process improvement.
  • Supports continuous improvement efforts by contributing insights that enhance review processes, criteria application, and workflow efficiency.

Job Qualifications

REQUIRED QUALIFICATIONS:
  • Registered Nurse (RN). License must be active and unrestricted in state of practice.
  • Requires a minimum of 2 years of experience in inpatient payment integrity medical claim review including DRG Validation or Itemized Bill Review, including 2 years' experience working with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS; or any combination of education and experience, which would provide an equivalent background.
  • Expert in DRG methodologies (e.g., MS & APR)
  • Expertise in UHDDS definitions, Official Inpatient Coding Guidelines, CMS and Medicaid State Guidelines for billing and coding, and AHA's Coding Clinic Guidelines
  • Expertise in evidence-based clinical decision support tools and clinical reference resources such as UpToDate, Merck Manual or similar
  • In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
  • Proven ability to apply critical judgment in clinical and coding determinations.
  • Experience working within applicable state, federal, and third-party regulations.
  • Analytic, problem-solving, and decision-making skills.
  • Organizational and time-management skills.
  • Attention to detail.
  • Critical-thinking and active listening skills.
  • Effective verbal and written communication skills.
  • Microsoft Office suite and applicable software program(s) proficiency.

PREFERRED QUALIFICATIONS:
  • Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Inpatient Coder (CIC), Clinical Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or other advanced HIM/coding certifications.
  • Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics (including high-acuity areas such as ICU, ED, PICU, or NICU).

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package.

About Molina Healthcare

Molina Healthcare focuses exclusively on government-sponsored health care programs for families and individuals who qualify for government-sponsored health care. It contracts with state governments and serves as a health plan, providing a wide range of quality health care services to families and individuals.

Molina Healthcare Careers

Join the dedicated team at Molina Healthcare, a leader in providing quality healthcare services to families and individuals who qualify for government-sponsored programs, including Medicaid and Medicare. As one of the most respected companies in the health services industry, Molina Healthcare offers unparalleled job opportunities aimed at empowering your career growth and professional development.

Work You’ll Do

At Molina Healthcare, you will engage in meaningful work that directly impacts lives across the country. Our team is committed to innovation in healthcare, ensuring that all members receive the best care possible. By joining us, you will collaborate with skilled professionals dedicated to our mission of providing accessible, high-quality healthcare.

Career Opportunities and Growth

Whether you are looking for your first job, seeking a leadership role, or aiming to specialize in healthcare professions, Molina Healthcare offers a range of career paths. Our job opportunities span across various functions, including clinical services, customer support, IT, project management, and more. We believe in fostering the growth of our employees through professional development, leadership training, and diversity initiatives.

Internship Programs

Kickstart your career with a Molina Healthcare internship. Our internships provide invaluable workplace experience, offering a glimpse into the healthcare industry through hands-on projects and mentorship. Interns at Molina Healthcare gain critical skills that prepare them for future employment, making them competitive candidates in the job market.

Culture and Benefits

Molina Healthcare is not just a company; it’s a community. We prioritize a culture of inclusivity and respect, where all team members are encouraged to bring their whole selves to work. Our employees enjoy comprehensive benefits, including health insurance, retirement plans, and wellness programs, all designed to support both their professional and personal lives.

Join Our Team

Explore the various positions available at Molina Healthcare and find where your skills and interests align with our needs. We are continuously hiring talented individuals who are passionate about making a difference in healthcare. Prepare your resume, sharpen your interview skills, and become part of a team that values hard work and creativity.

Stay Connected

Keep up to date with the latest at Molina Healthcare: - **Career Growth and Networking:** Advance your career through our professional development and networking opportunities. Learn from leaders and peers alike to build connections that propel your career forward. - **Innovation and Leadership:** Drive change and lead with confidence by participating in our leadership and innovation training programs.

Apply Now

Ready to take the next step in your healthcare career? Search open positions that match your skills and interests on the Molina Healthcare Jobs portal. We look for driven, curious, and compassionate team players ready to make an impact.

Stay Informed

Subscribe to Molina Healthcare job alerts and receive updates on new openings and company news directly to your inbox. Tailor your subscription to match your career preferences and stay ahead in the dynamic field of healthcare. Join Molina Healthcare, where your career is nurtured, your contributions are valued, and your growth is guaranteed.
Learn more about Molina Healthcare
Size
14,000 employees
Market Cap
$19.5 billion
Industry
Healthcare
Net Income
$673 million
Founded
1980
5 Year Trend
+9.3%
Revenue
$19.4 billion
NASDAQ
MOH
* Ladders Estimates

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