DRG Downgrade Clinical Documentation Improvement Revenue Integrity & Denials Mgmt

Position Overview

Responsible for clinical documentation review, validation, and improvement activities related specifically to DRG downgrades. Focuses on prevention and defense of DRG downgrades initiated by payers and third‑party audit firms through comprehensive documentation review, provider query support, and collaboration with clinical and denial management teams to support accurate DRG assignment and appeal success.

• Education:
  
  Graduate of an accredited school of nursing.
• Experience:
  
  Three years CDI experience required. Experience with DRG validation, clinical validation audits, or payer/audit DRG downgrades strongly preferred.
• Current CDI certification required (CCDS, CCDS‑O, CDIP, or equivalent).
• Other credentials:
  Registered Nurse – NJ.

• Expert knowledge of DRG methodology and clinical indicators supporting principal diagnosis and CC/MCC capture.
• Strong familiarity with payer and third‑party audit firm DRG downgrade methodologies.
• Knowledge of ICD‑10‑CM/PCS concepts as they relate to DRG assignment (coding credentials not required).
• Ability to identify documentation gaps and support compliant provider query opportunities.
• Strong written and verbal communication skills for clinical documentation clarification and education.
• Ability to collaborate effectively with physicians, CDI teams, clinical appeals staff, and denial specialists.
• Proficiency with electronic medical records and CDI tools; proficient in Microsoft Office.
• Must meet deadlines, pay attention to detail, demonstrate good judgment, and be metric‑driven and results oriented.

• Reviews inpatient cases targeted for DRG downgrade to assess documentation adequacy and DRG supportability.
• Identifies documentation gaps impacting DRG assignment and supports compliant provider query development.
• Collaborates with CDI teams and providers to clarify clinical documentation supporting DRG defense.
• Partners with Clinical Appeals RN and DRG Downgrade Denial Specialists to support appeal strategy and clinical evidence selection.
• Develops and maintains payer‑ and audit‑firm–specific DRG downgrade playbooks and documentation expectations.
• Identifies recurring DRG downgrade trends and escalates findings to leadership for targeted education and prevention.
• Supports appeal packet development by ensuring documentation clarity and clinical indicator alignment.
• Maintains current knowledge of DRG rules, clinical validation guidance, and payer audit practices.
• Participates in audits, education initiatives, and process improvement activities related to DRG integrity.
• Performs other duties as assigned and adapts to changing departmental demands.

Lifting Floor to Waist 15 lbs;
Lifting Waist Level and Above 10 lbs. Requires Accurate Near Vision and Minimal Hearing.

• Medical Plan, Prescription drug coverage & In‑House Employee Pharmacy, Dental Plan, Vision Plan.
• Flexible Spending Account (FSA), Healthcare FSA, Dependent Care FSA.
• Retirement Savings and Investment Plan.
• Basic Group Term Life and AD&D Insurance;
  Supplemental Group Term Life & AD&D Insurance.
• Disability Benefits – LTD, STD.
• Employee Assistance Program.
• Commuter Transit, Commuter Parking.
• Supplemental Life Insurance, Voluntary Life (Spouse, Employee, Child).
• Voluntary Legal Services;
  Voluntary Accident, Critical Illness and Hospital Indemnity Insurance.
• Voluntary Identity Theft Insurance.
• Voluntary Pet Insurance.
• Paid Time‑Off Program.

$39.40 – $51.47 per hour for a full‑time equivalent (1.0 FTE), 40 hours per week. Pay may vary based on experience, education, credentials and other factors.