Lead, Clinical Validation Reviewer (RN)

Company: Molina Healthcare | Location: Remote, United States | Employment: Full-time | License: RN | State licensure: Not Specified

Job Description Job Summary Provides lead level support for clinical validation review operations by assisting the Manager with workflow coordination, review consistency, calibration, training support, escalation, process improvement, and development of tools and resources that support timely, accurate, and defensible review outcomes. Performs advanced focused clinical reviews of claims to verify that coded diagnoses, procedures, revenue codes, billed charges, and corresponding reimbursement methodologies accurately reflect the patient’s documented clinical condition, services rendered, and applicable coding, billing, payer policy, and regulatory requirements. Leverages strong clinical reasoning, ICD-10 coding knowledge, DRG methodologies, revenue code logic, and evidence-based criteria to