CDI DRG Downgrade Specialist- Remote

Clinical Documentation Integrity Drg Downgrade Specialist

The Clinical Documentation Integrity DRG Downgrade Specialist is responsible for reviewing, analyzing, and responding to payer-initiated DRG downgrades. The Clinical Documentation Integrity DRG Downgrade Specialist ensures accurate DRG assignment, protects revenue integrity, and supports compliant documentation practices through detailed review, appeal preparation, and performance tracking. The Clinical Documentation Integrity DRG Downgrade Specialist serves as an effective change agent, acting as a resource and educator for providers and interdisciplinary care teams to improve documentation quality, coding accuracy, and audit readiness.

Duties & Responsibilities

• Analyze payer DRG downgrade notifications to determine validity based on ICD-10-CM/PCS coding guidelines, clinical indicators, and documentation sufficiency
• Conduct comprehensive medical record reviews to validate principal diagnosis, secondary diagnoses, procedures, MCC/CC capture, and DRG assignment accuracy
• Write clear, persuasive, evidence-based appeal letters that incorporate clinical rationale, coding guidelines, and regulatory references to support the original DRG
• Submit appeals within required timelines and track each case through all stages of the appeal lifecycle, including initial review, reconsideration, and final determination
• Maintain detailed logs of downgrade cases, outcomes, appeal success rates, and turnaround times to support throughput monitoring, trend analysis, and performance reporting
• Identify patterns in payer downgrades and escalate systemic issues or documentation vulnerabilities to leadership
• Collaborate with internal teams and providers to clarify ambiguous documentation and ensure clinical specificity
• Identify documentation gaps or inconsistencies and provide targeted feedback to improve provider documentation practices
• Participate in internal audits, retrospective reviews, and quality assurance processes related to DRG validation, coding accuracy, and documentation completeness
• Assist in developing or refining documentation templates, provider education materials, and query processes to support ongoing CDI improvement
• Ensure all coding and documentation practices align with CMS regulations, AHA Coding Clinic guidance, and organizational compliance policies
• Stay current on payer audit trends, regulatory updates, DRG methodology changes, and emerging risk areas that may impact DRG assignment or audit outcomes
• Support compliance initiatives by identifying potential vulnerabilities and recommending corrective actions or process improvements
• Partner with internal teams to resolve complex DRG issues and ensure alignment across departments
• Participate in provider education sessions, meetings, and case reviews to promote accurate documentation and DRG integrity
• Communicate effectively with leadership regarding trends, risks, and opportunities for improvement in documentation and coding practices
• Serve as a subject-matter expert for DRG downgrade processes, providing guidance and support to internal teams
• Other duties as assigned
• Use, protect and disclose patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

Qualifications

• Bachelor's degree in Nursing required
• Minimum of 3 years of experience in an inpatient clinical documentation improvement role
• Minimum of 5 years nursing experience in adult acute care in medical/surgical, critical care, emergency, and/or PACU setting
• RN license required
• CCDS and/or CDIP required
• CCS or CIC certification required
• Demonstrated inpatient coding experience in an acute care setting
• Prior experience managing DRG downgrades, including appeal letter development.
• Deep knowledge of ICD-10-CM/PCS, ICD-10 Official Coding Guidelines and both MS and APR DRG Reimbursement Systems
• Ability to interpret complex clinical documentation across multiple specialties.
• Proficiency with EMR systems, encoder tools (e.g., 3M, Optum) and CDI workflow and reporting tools
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the…