DRG Clinical Validation Reviewer (Coding RN)
for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We need to include only sections with real content.
We have job summary: "Eastern and Central time zones preferred. 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."
That's about the role. Could be "About the role". Then "Essential Job Duties" -> Responsibilities. Then "Required Qualifications" -> Requirements or Qualifications. Then "Preferred Qualifications" could be Skills? Or maybe separate "Preferred Qualifications" as Skills? The instruction: Use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can map:
- About the role: job summary paragraph.
- Responsibilities: Essential Job Duties list.
- Requirements: Required Qualifications (maybe also include RN license etc.)
- Qualifications: maybe Preferred Qualifications? But they said "Qualifications" heading could be for required? Actually they gave both Requirements and Qualifications as possible headings. We need to decide. Usually "Requirements" for required qualifications, "Qualifications" for preferred or additional qualifications. We'll do:
About the role
...summary...
Responsibilities
- ... each duty ...
Requirements
- ... required qualifications ...
Qualifications
- ... preferred qualifications ...
. Possibly split into multiple sentences but one
is fine. Responsibilities: Essential Job Duties list. Each bullet starts with a verb. We need to preserve all details. Let's extract each duty: - 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. We need to put each as
- .
Requirements: Required Qualifications list. Let's extract:
- 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.
We need to keep each as
- . Some are sentences; we can keep as is.
Qualifications: Preferred Qualifications list:
- 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. (This is application instruction; we must remove application instructions per rules: "Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions." So we should drop that line.)
- Molina Healthcare Offers a Competitive Benefits And Compensation Package. (This is benefits statement but vague; we might not include as it's not specific benefits; but it's not application instruction. However it's a generic statement; we might consider it filler? It's not a specific benefit; but it's not a placeholder like "not specified". It's a statement about benefits but not enumerated. The rule says: never emit a heading followed by filler/placeholder text (e.g., "commensurate with experience", "not specified", "N/A", "varies", "TBD") and never create Pay/Schedule/Benefits sections unless the posting actually states them. This is a benefits statement but vague; we could include it under Benefits section? But we decided not to include Benefits because it's not specific. However the line itself is a statement about benefits; we could include it as a
under Benefits? But we said we won't create Benefits section unless posting actually states them. It does state "Molina Healthcare Offers a Competitive Benefits And Compensation Package." That is a statement about benefits, albeit vague. The rule says: never create Benefits sections unless the posting actually states them. It does state a benefits statement, but it's not specific. However the rule also says: never emit a heading followed by filler/placeholder text (e.g., "commensurate with experience", "not specified", "N/A", "varies", "TBD"). "Competitive Benefits And Compensation Package" is not exactly placeholder but could be considered vague. I'd lean to not include Benefits section because it's not specific details. We'll omit that line. - Pay Range: $26.14 - $56.64 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. This is pay info; we will include in Pay section. - Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. This is EEO boilerplate; remove. Thus for Preferred Qualifications we keep only the two bullet points: