Lead Medical Claim Review Nurse (RN) - Remote in California

Job Summary

The Lead, DRG Coding & Validation (RN) develops tools and process improvements based on identified trends to ensure that claims are settled in a timely fashion and in accordance with quality reviews of appropriate ICD-10-CM and/or CPT codes as well as accurate Diagnosis Related Group (DRG) or Ambulatory Payment Classification (APC) assignments. Responsible for auditing inpatient medical records and generating high quality claims payment to ensure payment integrity.  Responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy.

Knowledge/Skills/Abilities

• Key contributor in developing the DRG validation tools to build workflow processes, training, audits, and production management.  


• Identify potential claims outside of the current concepts where additional opportunities may be available. Suggests and develops high quality, high value concepts and or process improvements, tools, etc.


• Integrates medical chart coding principles, clinical guidelines, and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.


• Influences and engages team members across functional teams to achieve results both remotely and onsite.


• Facilitates and provides support to other team members in development and training.


• Responsible for developing and maintaining job aids to ensure accuracy.


• Escalates claims to Medical Directors, Health Plan, Claims team; works directly with a variety of leaders throughout the organization.


• Facilitates updates or changes to ensure coding guidelines are established and followed within the Health Information Management Department and by National Correct Coding Initiatives (NCCI), and other relevant coding guidelines.


• Ensures CMS/Medicaid guidelines around Multiple Procedure Payment Reductions and other mandated pricing methodologies are implemented and followed.


• Support the development of auditing rules within software components to meet CMS regulatory mandates.


• Utilizes Molina proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters and train team members.


• Performing other duties as assigned.

Job Qualifications

REQUIRED EDUCATION:

Bachelor’s Degree in Nursing or Health Related Field

REQUIRED EXPERIENCE:

• 5+ years Clinical Nursing experience


• 5+ years of experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG/ Clinical Validation


• 3+ years of Utilization Review and/or Medical Claims Review experience.


• 5+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.


• Requires strong knowledge in coding: DRG, ICD-10, CPT, HCPCS codes.


• Proficiency in Word, Access, Excel and other applications.


• Excellent written and verbal communication skills.


• Extensive background in either facility-based nursing and/or inpatient coding and has a high level of understanding in reimbursement guidelines specifically related to MS-DRG, AP-DRG and APR-DRG payment systems.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Active and unrestricted State Registered Nursing (RN) License in good standing.

PREFERRED EDUCATION:

Master's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

7+ years Clinical Nursing experience

5+ years of experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG/ Clinical Validation

1+ years Training & Education

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

Certified Coding Specialist (CCS), (CIC), Certified Professional Coder (CPC) License in good standing and certification current. Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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