Clinical Validation Reviewer (Coding RN)
M
Molina HealthcareHealthcare
United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- At least 2 years of experience in inpatient payment integrity medical claim review including DRG validation or itemized bill review.
- Required Skills
- Microsoft Office
Requirements
- Registered Nurse (RN) with an active and unrestricted license.
- At least 2 years of experience in inpatient payment integrity medical claim review, including DRG validation or itemized bill review.
- Advanced knowledge of DRG methodologies (MS-DRG, AP-DRG, APR-DRG).
- Expertise in ICD-10 coding, UHDDS definitions, and inpatient coding guidelines.
- Knowledge of CMS and Medicaid state guidelines, as well as AHA coding clinic guidelines.
- Proficiency in clinical decision support tools (e.g., UpToDate, Merck Manual).
- Experience applying critical judgment to clinical and coding determinations.
- Proficiency in Microsoft Office suite.
- Effective verbal and written communication skills.
- Strong analytical, problem-solving, and time-management skills.
Responsibilities
- Review inpatient and outpatient claims to ensure accuracy of diagnoses, procedures, revenue codes, and DRG assignments.
- Integrate ICD-10 coding principles, DRG methodologies, and evidence-based clinical guidelines into claim reviews.
- Perform DRG validation reviews and itemized bill reviews to identify unsupported or inaccurate billing elements.
- Develop evidence-based written rationales to support diagnosis and coding determinations.
- Collaborate with coding, payment integrity, and physician advisors to clarify clinical documentation and reimbursement issues.
- Meet established productivity goals and maintain accuracy standards for all review activities.
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