Lead, Clinical Validation Reviewer (RN)

Molina Healthcare•United States,

16h•$59,811 - $129,590

About The Position

Provides lead level support for clinical validation review operations by assisting the Manager with workflow coordination, review consistency, calibration, training support, escalation, process improvement, and development of tools and resources that support timely, accurate, and defensible review outcomes. Performs advanced focused clinical reviews of claims to verify that coded diagnoses, procedures, revenue codes, billed charges, and corresponding reimbursement methodologies accurately reflect the patient’s documented clinical condition, services rendered, and applicable coding, billing, payer policy, and regulatory requirements. Leverages strong clinical reasoning, ICD-10 coding knowledge, DRG methodologies, revenue code logic, and evidence-based criteria to assess medical records for clinical accuracy, acuity alignment, documentation integrity, reimbursement impact, and payment integrity.

Requirements

Registered Nurse (RN). License must be active and unrestricted in the state of practice.
Requires a minimum of 3 years of experience in payment integrity medical claim review, including DRG validation, itemized bill review, clinical validation, or coding/reimbursement-focused claim review, and experience working with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS, revenue codes, and related coding, billing, and reimbursement guidelines; or any combination of education and experience which would provide an equivalent background.
Demonstrated experience serving as a reviewer, preceptor, trainer, calibration resource, or escalation resource in a payment integrity, clinical validation, DRG validation, itemized bill review, or claims audit environment.
Ability to provide lead-level guidance to clinical review staff, support review consistency, and assist with resolution of complex clinical, coding, billing, documentation, or reimbursement issues.
Experience supporting workflow coordination, calibration, quality review, training, job aid development, process improvement, or operational readiness activities in a clinical validation or payment integrity review environment.
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.
Ability to support workflow coordination and review consistency.
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.

Nice To Haves

Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)
Claims auditing, quality assurance, or recovery auditing, ideally in DRG/clinical validation.
Training and education experience.

Responsibilities

Assists the Manager with day-to-day clinical validation review operations, including workflow coordination, review prioritization, case routing support, follow-up, and escalation of complex or high-risk issues.
Provides lead-level clinical, coding, reimbursement, and payment integrity guidance for claim reviews.
Performs advanced focused clinical reviews claims to verify that coded diagnoses, procedures, revenue codes, billed charges, and corresponding reimbursement methodologies accurately reflect the patient’s documented clinical condition and services rendered.
Assesses medical records, claim data, billing details, and related documentation for clinical accuracy, acuity alignment, documentation integrity, coding validity, charge support, and reimbursement impact.
Applies ICD-10-CM/PCS coding principles, DRG methodologies, CPT/HCPCS code logic, revenue code logic, evidence-based clinical criteria, payer policies, billing guidelines, and applicable federal and state regulatory requirements.
Identifies unsupported, inaccurate, or inappropriate coding, billing, documentation, revenue code, charge, or reimbursement elements that may impact payment accuracy.
Develops and supports clear, evidence-based rationales for clinical validation findings, recommendations, audit determinations, and claim review outcomes.
Supports consistency across review work by facilitating calibration discussions, case reviews, knowledge-sharing, and application of review standards.
Performs quality checks, secondary reviews, or targeted review support assigned to identify documentation gaps, rationale inconsistencies, training needs, or process opportunities.
Supports onboarding, training, and ongoing education for clinical validation review staff, including development and maintenance of job aids, review tools, templates, and workflow resources.
Identifies trends, patterns, and emerging opportunities in clinical documentation, coding, billing, revenue code use, billed charges, or reimbursement methodology and escalates findings to the Manager with recommended actions.
Collaborates with coding, claims, SIU, physician advisors, health plan partners, vendors, and other internal stakeholders to resolve complex review issues, support escalations, and promote accurate review outcomes.
Supports development, testing, and refinement of clinical validation review tools, audit resources, workflow processes, system logic, and process improvements.
Utilizes Molina systems and applicable review platforms to document determinations, support audit outcomes, generate correspondence, and assist with consistent workflow execution.
Supports special projects and implementation activities related to clinical validation, claim review, payment integrity, and reimbursement accuracy.