Manager, DRG Coding & Validation (RN) Remote

Lensa - Mesa, AZ

Job Title: Manager, DRG Coding & Validation (RN) Remote

Position: Manager

Job Type: Full Time

Pay: $77,969 - $171,058 / ANNUAL

Shift: Monday - Friday: 7:00 AM - 5:00 PM EST

Work Type: Remote

Location

Address:

City: Mesa

State: AZ

ZIP Code:

Job Responsibilities

Key participant in the development and implementation of the DRG validation program.
Audit inpatient medical records to generate high quality claims payment and ensure payment integrity.
Perform clinical reviews of medical records and documentation to evaluate coding and DRG assignment accuracy.
Ensure claims are settled timely and in accordance with quality reviews of ICD-10-CM and/or CPT codes.
Manage medical claim review team nurses, ensuring operational goals are met through team productivity.
Provide monthly feedback and develop work plans for team members.
Coordinate and conduct ongoing training for employees as needed.
Identify potential claims outside of the concept for additional opportunities.
Develop and maintain job aids; conduct quarterly reviews and updates as needed.
Support the development of auditing rules within software components to meet CMS regulatory mandates.
Escalate claims to Medical Directors, Health Plan, Claims team as required.
Ensure compliance with established coding guidelines and CMS guidelines.

Required Skills

Core Skills

Extensive background in facility-based nursing and inpatient coding
High level understanding in reimbursement guidelines (MS-DRG, AP-DRG, APR-DRG)
Advanced ICD-10 coding expertise
Exposure to medical claims billing/payment systems and payer reimbursement policies
Proficiency in Microsoft Word, Access, Excel and auditing systems

Preferred Skills

Master's Degree or equivalent combination of education and experience
Experience in training and education related to clinical validation

Requirements

Experience: 7+ years Clinical Nursing experience; 5+ years in claims auditing, ideally in DRG/ Clinical Validation; 3+ years Utilization Review or Medical Claims Review experience; 3+ years Managerial Experience

Education: Bachelor's Degree in Nursing or Health Related Field

License & Certification:

Active, unrestricted State Registered Nursing (RN)
Certified Coding Specialist (CCS) or Certified Internal Coding (CIC) in good standing

Schedule:

Not specified

COVID-19 Requirements: Not Specified

Benefits

Competitive benefits and compensation package

Supplemental Pay

Not specified

Special Notes

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Actual compensation may vary based on geographic location, work experience, education and/or skill level.