DRG Downgrade Clinical Documentation Improvement Revenue Integrity & Denials Mgmt

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range: $39.40 - $51.47

Scheduled Weekly

Hours:

40

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 required.

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 complication/comorbidity (CC/MCC) capture
• Strong familiarity with payer and third-party audit firm DRG downgrade methodologies
• Working 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 non-clinical denial specialists
• Proficiency with electronic medical records and CDI tools

Special Training:
Proficient in Microsoft Office.

• Must have ability to meet deadlines and attention to detail.
• Must demonstrate good judgment.
• Must be metric-driven and results oriented.

Usual Work Day: 8 Hours

Does this position formally supervise employees? No. If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

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.

Frequent physical demands include:
Occasional physical demands include:
Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include:
Accurate Near Vision, Minimal Hearing Anticipated Occupational Exposure Risks Include the following: N/A

This position is eligible for the…