Healthcare - Medical Claim Review Nurse

Clinical Validation Reviewer

Focused review of professional claims related to Fraud Waste and Abuse, documentation review to support services provided from billing and coding perspective, ensure all state/federal guidelines are utilized, document findings, identify trends, this is a production environment.

Performs focused clinical reviews of inpatient and outpatient claims to verify that coded diagnoses, procedures, revenue codes, and corresponding reimbursement methodologies accurately reflect the patient'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.

Expert in DRG methodologies (e.g., MS & APR), 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, Client 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. Attention to detail. Critical-thinking and active listening skills. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency.

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.

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. Registered Nurse (RN). License must be active and unrestricted in state of practice. Preferred: 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.