Lead, DRG Coding / Validation (RN)

JOB DESCRIPTION Job Summary

Provides lead level support developing diagnosis-related group (DRG) validation tools and process improvements - ensuring that member medical claims are settled in a timely fashion and in accordance with quality reviews of appropriate ICD-10 and / or CPT codes, and accuracy of DRG or ambulatory payment classification (APC) assignments. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Develops diagnosis-related group (DRG) validation tools to build workflow processes and training, auditing and production management resources.
• Identifies potential claims outside of 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.
• Audits inpatient medical records and generates high-quality claims payment to ensure payment integrity.
• Performs clinical reviews of medical records and other utilization management documentation to evaluate issues of coding and DRG assignment accuracy.
• Collaborates and / or leads special projects.
• Influences and engages team members across functional teams.
• Facilitates and provides support to other team members in development and training.
• Develops and maintains job aids to ensure accuracy.
• Escalates claims to medical directors, health plans and claims teams, and collaborates 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 (HIM) department and by National Correct Coding Initiatives (NCCI), and other relevant coding guidelines.
• Ensures care management and Medicaid guidelines around multiple procedure payment reductions and other mandated pricing methodologies are implemented and followed.
• Supports the development of auditing rules within software components to meet care management regulatory mandates.
• Utilizes Molina proprietary auditing systems with a high-level of proficiency to make audit determinations, generate audit letters and train team members.

Required Qualifications

Preferred Qualifications

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

Pay Range : $76,425 - $149,028 / ANNUAL

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V.

Job Type Full Time Posting Date 02 / 24 / 2026