Molina Healthcare

Job Description

Job Summary

The Manager, Clinical DRG Coding & Validation must have an extensive background in either facility-based nursing and/or inpatient coding and has a high level of understanding in reimbursement guidelines specifically related to MS-DRG, AP-DRG and APR-DRG payment systems. Key participant in the development and implementation of the DRG validation program. Responsible for auditing inpatient medical records and generating high quality claims payment to ensure payment integrity. Responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy.

Ensures that claims are settled in a timely fashion and in accordance with quality reviews of appropriate ICD-10-CM and/or CPT codes as well as accurate Diagnosis Related Group (DRG) or Ambulatory Payment Classification (APC) assignment for timely and accurate reimbursement and data collection. Candidates with previous management and DRG validation experience are highly preferred.

Work hours: Monday - Friday: 7:am - 5:00PM EST

Remote position

Unrestricted RN licensure required

Knowledge/Skills/Abilities

• Key role in developing and implementing the DRG validation program to build tools, workflow process, training, audits, and production management.
• Integrates medical chart coding principles, clinical guidelines, and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently.
• Utilizes Molina proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters, train team members.
• Manage medical claim review team nurses, ensure operational goals are meet and maintained through team productivity as key performance indicators.
• Ensure team members achieve the expected level of accuracy and quality, for valid claim identification, decision making, and documentation. Provide monthly feedback and develop workplan as appropriate.
• Coordinates and conducts on-going training for all employees as needed; delegates to Lead as appropriate to ensure new hires are trained
• Ability to influence and engage direct and indirect reports as well as peers to achieve results both remotely and onsite.
• Provides leadership and development to all workforce staff including assistance in development and training.
• Identify potential claims outside of the concept where additional opportunities may be available. Suggests and develops high quality, high value concept and or process improvement, tools, etc.
• Develops and maintains Job Aids; conduct quarterly reviews, update as needed.
• Escalates claims to Medical Directors, Health Plan, Claims team; works directly with variety of leaders throughout organization.
• Ensuring coding guidelines as established within the Health Information Management Department and by National Correct Coding Initiatives (NCCI), and other relevant coding guidelines.
• Ensuring CMS guidelines around Multiple Procedure Payment Reductions and other mandated pricing methodologies specific to Medicaid.
• Support the development of auditing rules within software components to meet CMS regulatory mandates.
• Performing other duties as assigned.

Job Qualifications

Required Education

Bachelor's Degree in Nursing or Health Related Field

Required Experience

• 7+ years Clinical Nursing experience
• 5+ years of experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG/ Clinical Validation
• 3+ years of Utilization Review and/or Medical Claims Review experience.
• 3+ years Managerial Experience
• 5+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
• Requires strong knowledge in coding: DRG, ICD-10, CPT, HCPCS codes.
• Proficiency in Word, Access, Excel and other applications.
• Excellent written and verbal communication skills.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN) and Certified Coding Specialist (CCS) or (CIC)

License in good standing and certification current.

Preferred Education

Master's Degree or equivalent combination of education and experience

Preferred Experience

7+ years Clinical Nursing experience

5+ years of experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG/ Clinical Validation

1+ years Training & Education

Preferred License, Certification, Association

Active and unrestricted Registered Nurse (RN) license and Certified Coding Specialist (CCS), (CIC), Certified Professional Coder (CPC) License in good standing and certification current. Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $171,058 / ANNUAL

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full Time Posting Date: 06/12/2025