Remote DRG Clinical Validation Reviewer (Coding RN)

Job Summary

Performs focused clinical reviews of inpatient and outpatient claims to verify accurate coding and reimbursement.

Job Duties

• Reviews inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, itemized charges, and 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.
• Conducts 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.
• 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.
• Maintains consistency and strengthens review competency through participation in quality checks, calibration sessions, and ongoing training.
• 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.

Job Qualifications

• Registered Nurse (RN). License must be active and unrestricted in state of practice. Requires a minimum of 2 years of experience in inpatient payment integrity medical claim review including DRG Validation or Itemized Bill Review, including 2 years’ experience working with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS; or any combination of education and experience, which would provide an equivalent background.
• 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
• 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
• 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

• Advanced HIM/coding certifications (e.g., CCS, RHIA, RHIT, CIC, CDIP, CPC)
• Nursing experience in critical care, emergency medicine, medical/surgical, or pediatrics (including high-acuity areas such as ICU, ED, PICU, or NICU)