RN DRG Downgrades Appeals Review Specialist

St. Luke's University Health Network•Allentown, PA

About The Position

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The RN DRG Downgrades Appeals Review Specialist is responsible for the retrospective clinical review and defense of inpatient DRG downgrades, clinical validation denials, and medical necessity determinations issued by governmental and commercial payers.

Requirements

Registered Nurse required.
Active RN license required.
Minimum five (5) years RN experience in adult inpatient acute care (medical/surgical or critical care).
Familiarity with MS-DRG reimbursement methodology.
Demonstrated understanding of disease pathophysiology and documentation specificity requirements.
Working knowledge of ICD-10-CM/PCS fundamentals.
Understanding of payer audit and appeal processes.

Nice To Haves

BSN preferred.
CDI certification (CDIP, CCDS) preferred.
Strongly preferred: Clinical Documentation Improvement (CDI) experience.
Strongly preferred: DRG downgrade or clinical validation denial experience.
Strongly preferred: Utilization review or payer medical review experience.
Experience with EPIC and encoder tools (e.g., 3M) preferred.

Responsibilities

Conduct retrospective clinical record reviews to evaluate DRG downgrades, clinical validation denials, and medical necessity determinations.
Analyze documentation in conjunction with MS-DRG logic and ICD-10-CM/PCS coding guidelines to determine appeal opportunity.
Develop and submit defensible first- and second-level appeal letters using clinical evidence, regulatory guidance, coding standards, and payer policy.
Collaborate with Physician Advisors, Coding leadership, and CDI to support higher-level appeals (e.g., IRO, ALJ, payer conferences).
Identify denial trends and provide structured feedback to Coding and CDI leadership to reduce future payer vulnerability.
Participate in payer audit response processes (RAC, QIO, MIC, commercial auditors) and assist in preparation for formal appeal proceedings.
Maintain accurate documentation within EPIC, payer audit platforms, and internal tracking tools to support reporting and performance monitoring.
Review denial data and appeal outcomes to assist leadership in assessing revenue impact, case resolution trends, and operational improvement opportunities.
Maintain current knowledge of MS-DRG methodology, ICD-10-CM/PCS coding guidelines, clinical validation standards, federal and commercial payer policies, and medical necessity criteria.
Serve as a clinical resource regarding documentation specificity and disease process validation as it relates to reimbursement defense.