DRG Downgrade Clinical Documentation Improvement - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Capital Health (US) • Pike, NY

1d • Onsite

About The Position

Capital Health is seeking a DRG Downgrade Clinical Documentation Improvement professional to join their Revenue Integrity & Denials Management team. This full-time, day shift position is responsible for reviewing, validating, and improving clinical documentation specifically related to DRG downgrades. The role focuses on preventing and defending against DRG downgrades initiated by payers and third-party audit firms. This involves comprehensive documentation review, supporting provider queries, and collaborating with clinical and denial management teams to ensure accurate DRG assignment and successful appeals.

Requirements

• Graduate of an accredited school of nursing required.
• Three years' CDI experience required.
• Current CDI certification required (CCDS, CCDS-O, CDIP, or equivalent).
• 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.
• 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.

Nice To Haves

• Experience with DRG validation, clinical validation audits, or payer/audit DRG downgrades strongly preferred.

Responsibilities

• 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.

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree