Remote DRG Clinical Validation Reviewer (Coding RN)

Job Description

Job Summary Performs focused clinical reviews of inpatient and outpatient claims to verify that coded diagnoses, procedures, reputed company codes, and corresponding reimbursement methodologies accurately reflect the patient’s documented clinical condition, services rendered, and billed charges. Assesses medical records for clinical accuracy, reputed company alignment, and documentation reputed company. Identifies inconsistencies that impact reimbursement such as unsupported diagnoses, incorrect procedure coding, or inaccurate reputed company 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, reputed company codes, itemized charges, and Diagnostic reputed company Groups (DRG) assignments accurately reflect the documented clinical condition and services provided. Integrates ICD‑10 coding principles, DRG methodologies, reputed company code logic, and evidence‑based clinical guidelines reputed company reviewing claims for accuracy, appropriateness, and alignment with documentation. Performs DRG validation reviews by verifying reputed company and secondary diagnoses, complications/comorbidities, procedure coding, severity level, and correct grouping logic. Conducts itemized reputed company 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 reputed company code usage. Develops clear, evidence‑based written rationales supporting diagnosis, procedure, reputed company code, or DRG recommendations and determinations. Substantiates reputed company review reputed company using clinical indicators, documentation, coding guidelines, payer policy, and regulatory requirements. Performs review work independently, applying sound clinical judgment and specialized expertise to evaluate reputed company claim scenarios. Applies applicable federal/state regulations, official coding guidelines, payer policies, and Molina Payment reputed company standards during reputed company reviews. Ensures compliance with DRG and itemized reputed company review criteria, clinical validation rules, and reimbursement methodologies. Collaborates with coding, payment reputed company analytics, SIU, and physician advisors to clarify reputed company clinical documentation, coding discrepancies, or reimbursement determinations. Provides subject‑matter expertise on DRG validation, reputed company code accuracy, itemized reputed company review, and documentation reputed company to internal partners as needed. Meets or exceeds established productivity goals set by Payment reputed company leadership for clinical validation and claim review activities. Achieves the required accuracy and quality standards for review, diagnosis/procedure validation, and/or itemized reputed company 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 reputed company 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 reputed company medical claim review including DRG Validation or Itemized reputed company 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 reputed company an equivalent background. Expert in DRG methodologies (e.g., MS & APR) Expertise in UHDDS definitions, Official Inpatient Coding Guidelines, CMS and reputed company 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 reputed company, reputed company reputed company 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 reputed company applicable state, federal, and reputed company-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. reputed company Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Coding Specialist (reputed company), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Inpatient reputed company (CIC), Clinical Documentation Improvement Practitioner (CDIP), Certified Professional reputed company (CPC), or other advanced HIM/coding certifications. Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics (including high‑reputed company areas such as ICU, ED, PICU, or NICU). To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the Internal reputed company. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V. Apply To This Job