Eastern and Central time zones preferred.
Job Summary
Provides support for inpatient and outpatient clinical claim review activities.
Verifies that coded diagnoses, procedures, revenue codes, and corresponding
reimbursement methodologies accurately reflect the member'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. Contributes to overarching strategy to provide quality
and cost-effective member care.
Essential 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.
Required Qualifications
• At least 2 years of experience in inpatient payment integrity medical claim
review including DRG validation or itemized bill review, and experience working
with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS, or equivalent combination
of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of
practice.
• Advanced in DRG methodologies.
• Expertise in UHDDS definitions, official inpatient coding guidelines, Centers
for Medicare and Medicaid (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 and 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.
Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.