Clinical Validation Reviewer (RN) - Inpatient Coding & Reimbursement

Molina Healthcare•Long Beach, CA

About The Position

The Clinical Validation Reviewer provides support for inpatient and outpatient clinical claim review activities. The role verifies that coded diagnoses, procedures, revenue codes, and reimbursement methodologies accurately reflect members’ documented clinical conditions, services rendered, and billed charges. It assesses medical records for clinical accuracy, acuity alignment, and documentation integrity, and identifies discrepancies that may affect reimbursement. This is not a traditional bedside nursing role. The reviewer applies clinical judgment and expertise in coding, DRG methodologies, reimbursement guidelines, clinical documentation, payer policies, and regulatory requirements. The position also collaborates with internal partners, supports quality and process improvement, and meets established productivity and accuracy standards.

Requirements

At least 2 years of experience in inpatient payment integrity medical claim review, including DRG validation or itemized bill review, and experience with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS, or an equivalent combination of relevant education and experience.
Active, unrestricted Registered Nurse (RN) license in the state of practice.
Advanced knowledge of DRG methodologies.
Expertise in UHDDS definitions, official inpatient coding guidelines, CMS and state Medicaid billing and coding guidelines, and AHA Coding Clinic guidelines.
Expertise with 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 supporting code assignments.
Ability to apply critical judgment in clinical and coding determinations.
Experience working within applicable state, federal, and third-party regulations.
Analytical, 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.
Proficiency with Microsoft Office and applicable software programs.

Nice To Haves

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 certification.
Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics, including high-acuity areas such as ICU, ED, PICU, or NICU.

Responsibilities

Review inpatient and/or outpatient claims to confirm that diagnoses, procedures, revenue codes, itemized charges, and DRG assignments accurately reflect documented conditions and services.
Apply ICD-10 coding principles, DRG methodologies, revenue code logic, and evidence-based clinical guidelines to assess claim accuracy and appropriateness.
Perform DRG validation, including verification of principal and secondary diagnoses, complications and comorbidities, procedure coding, severity level, and grouping logic.
Review itemized bills to confirm charges are supported by documentation, comply with billing standards, and are appropriate for the level of care delivered.
Identify unsupported, inaccurate, or inappropriate coding and billing elements, including unsubstantiated diagnoses, incorrect procedures, or incorrect revenue code usage.
Develop clear, evidence-based written rationales for diagnosis, procedure, revenue code, and DRG recommendations and determinations.
Substantiate review outcomes with clinical indicators, documentation, coding guidelines, payer policy, and regulatory requirements.
Independently evaluate complex claim scenarios using sound clinical judgment and specialized expertise.
Apply applicable federal and state regulations, official coding guidelines, payer policies, and Molina payment integrity standards.
Ensure compliance with DRG and itemized bill review criteria, clinical validation rules, and reimbursement methodologies.
Collaborate with coding, payment integrity analytics, SIU, and physician advisors on complex documentation, coding, and reimbursement matters.
Provide subject matter expertise on DRG validation, revenue code accuracy, itemized bill review, and documentation integrity.
Meet or exceed productivity goals and required accuracy and quality standards for review activities.
Participate in quality checks, calibration sessions, and ongoing training.
Complete special projects and additional review assignments as delegated by leadership.
Identify patterns and trends that may require escalation, provider education, or process improvement.
Contribute insights to continuous improvement of review processes, criteria application, and workflow efficiency.