DRG Downgrade Denial Specialist - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

Capital Health (US)•Pike, NY

1d•Onsite

About The Position

Responsible for administrative management, tracking, and resolution coordination of DRG downgrade denials across all payers and third-party audit firms. Ensures DRG downgrade cases are properly triaged, routed, documented, tracked, and submitted in accordance with payer and auditor requirements, while partnering with clinical resources to support successful appeal outcomes and denial prevention.

Requirements

High school diploma or equivalent required.
Three years' hospital billing, denials management, appeals coordination, or related revenue cycle experience.
Experience working DRG downgrades, payer audits, or post-payment reviews strongly preferred.
CCS
Working knowledge of DRG downgrade processes and third-party audit workflows
Strong understanding of hospital billing systems and payer claim adjudication processes
Ability to perform detailed tracking, documentation, and inventory management across multiple appeal levels
Strong organizational skills and attention to detail
Ability to perform root-cause analysis and identify recurring downgrade drivers
Strong written communication skills for documentation and internal coordination
Proficiency with Microsoft Office applications, including Excel.
Must have ability to meet deadlines and attention to detail.
Must demonstrate good judgment.
Must be metric-driven and results oriented.

Nice To Haves

Associate or bachelor’s degree in healthcare or business-related field preferred.

Responsibilities

Reviews and triages all DRG downgrade cases (pre-pay and post-pay), including payer-initiated and third-party audit firm reviews
Ensures DRG downgrade cases are routed to appropriate resources (CDI RN, Clinical Appeals RN, coding/CDI teams as needed)
Maintains accurate DRG downgrade inventories, including deadlines, appeal levels, documentation status, and outcomes
Coordinates medical record requests, appeal packet assembly logistics, and submission tracking
Ensures compliance with payer and auditor requirements, timelines, and documentation standards
Performs payer and auditor follow-up activities, including portal research and telephone outreach as needed
Documents clear, concise, and accurate notes in the hospital billing system related to downgrade actions and status
Identifies recurring DRG downgrade trends by payer, service line, diagnosis, or audit firm and escalates findings to leadership
Supports denial prevention initiatives by partnering with CDI, UR, and operational teams on recurring downgrade drivers
Performs other duties as assigned and adapts to changing departmental demands