Manager, Clinical Validation (RN)

EASTERN OR CENTRAL TIME ZONES PREFERRED.

Job Summary

Manages Clinical Validation Payment Integrity review operations for assigned review programs, overseeing DRG validation, itemized bill review, revenue code and/or charge validation, clinical documentation review, and related coding, billing, and reimbursement accuracy activities. Accountable for understanding the clinical, coding, billing, reimbursement, regulatory, operational, and contractual requirements of the assigned review program and ensuring review outcomes are accurate, consistent, timely, and defensible. Oversees day-to-day production, review quality, calibration, training, escalation, operational readiness, and process improvement activities that align with Molina Payment Integrity standards, payer policy, coding, and billing guidelines, and applicable federal and state regulatory requirements. Partners cross-functionally with claims, coding, SIU, physician advisors, health plan partners, vendors, and other stakeholders to resolve complex issues, improve workflow performance, and support accurate and cost-effective claim payment.

Job Duties

• Manages assigned Clinical Validation Payment Integrity review programs, including inpatient and/or outpatient claim review operations such as DRG validation, itemized bill review, and other payment integrity claim reviews. Oversees workflow, inventory, prioritization, turnaround times, operational controls, and review execution to ensure timely, accurate, and defensible outcomes.
• Maintains strong working knowledge of assigned review programs, including clinical review criteria, coding and billing requirements, reimbursement methodology, provider billing patterns, system workflows, operational controls, regulatory considerations, and program-specific risks. Ensures determinations are supported by medical record documentation, clinical indicators, official coding guidance, payer policy, Molina Payment Integrity standards, and applicable federal and state requirements.
• Establishes and monitors productivity, accuracy, quality, rationale documentation, inventory, aging, and other operational performance metrics. Leads calibration, quality review, secondary review, training, coaching, and knowledge-sharing activities to promote review consistency and strengthen team performance.
• Reviews and resolves escalated cases, rationale disputes, provider or health plan questions, coding or documentation inconsistencies, and operational barriers that may affect payment accuracy or regulatory defensibility. Collaborates with claims, coding, SIU, physician advisors, provider-facing teams, health plan partners, vendors, analytics, IT, and other stakeholders to support issue resolution, process improvement, and implementation readiness.
• Identifies trends, outliers, process gaps, provider billing patterns, documentation issues, coding inconsistencies, and emerging payment integrity opportunities. Supports development, testing, refinement, and implementation of clinical validation workflows, audit tools, review platforms, correspondence templates, reporting, operational controls, and strategic initiatives.
• Ensures team documentation, review rationales, audit letters, and determinations are clear, evidence-based, consistent, and appropriate for internal, provider, vendor, health plan, and regulatory audiences. Manages staffing, workload balancing, performance development, team engagement, and day-to-day people leadership responsibilities.

REQUIRED QUALIFICATIONS:

• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).
• At least 7 years of experience in payment integrity, medical claim review, claims auditing, recovery auditing, clinical validation, DRG validation, itemized bill review, coding/reimbursement-focused claim review, or related healthcare audit operations.
• At least 2 years of people leadership, supervisory, team lead, or operational management experience in a clinical, claims, audit, payment integrity, or related healthcare environment.
• Experience leading or overseeing review operations that require application of clinical documentation, coding, billing, reimbursement methodology, payer policy, and regulatory requirements to determine claim payment accuracy.
• Working knowledge of ICD-10-CM/PCS, MS-DRG, AP-DRG, APR-DRG, CPT, HCPCS, revenue codes, billed charges, provider billing guidelines, payer reimbursement policies, medical claims billing/payment systems, and coding terminology.
• Knowledge of UHDDS definitions, Official Inpatient Coding Guidelines, CMS and Medicaid state billing and coding guidance, AHA Coding Clinic guidance, payer policy, and applicable federal, state, and third-party regulations.
• Ability to lead review quality, calibration, productivity management, escalation resolution, operational reporting, and cross-functional issue resolution in a matrixed healthcare environment.
• Ability to apply clinical judgment, coding and reimbursement knowledge, and regulatory awareness to complex claim review, escalation, and operational decision-making.
• Strong analytical, problem-solving, decision-making, organizational, time-management, written communication, verbal communication, and coaching skills.
• Microsoft Office suite and applicable software program expertise.

PREFERRED QUALIFICATIONS:

• Experience managing mature payment integrity review programs such as DRG validation, itemized bill review, revenue code validation, charge review, clinical validation, or other coding and reimbursement accuracy reviews in a payer, managed care, recovery audit, or vendor oversight environment.
• Experience with Medicaid, Medicare Advantage, managed care, state-specific payment policy, provider audit response, audit correspondence, regulatory-facing documentation, or government program requirements.
• Experience developing, implementing, or governing review criteria, job aids, quality programs, calibration models, operational dashboards, reporting, training materials, process controls, audit tools, or implementation readiness plans.
• Experience partnering with claims, coding, analytics, IT, SIU, physician advisors, vendors, health plans, or provider-facing teams to resolve complex payment accuracy issues and improve review program performance.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.