Sign upLog in

Clinical Documentation Integrity DRG Downgrade Specialist- Remote

Med-Metrix

Parsippany-Troy Hills, NJ(remote)

Apply
JOB DETAILS
JOB TYPE
Full-time
SKILLS
Acute Care, Analysis Skills, Authentication, Certified Coding Specialist (CCS), Clinical Study Publications, Communication Skills, Computer Security, Content Management Systems (CMS), Corrective Action, Critical Care, Diagnosis-Related Group (DRG), Documentation, Electronic Medical Records, Emergency Care, Genetics, HIPAA (Health Insurance Portability and Accountability Act), ICD-10, Identify Issues, Information/Data Security (InfoSec), Internal Audit, International Classification of Diseases (ICD), Interpersonal Skills, Leadership, Maintain Compliance, Medical Coding, Medical Records, Medical Treatment, Microsoft Office, Military, Nursing, Office Equipment, Patient Care, People Management, Performance Analysis, Peripheral Hardware, Persuasion Skills, Postanesthesia, Presentation/Verbal Skills, Problem Solving Skills, Quality Assurance Methodology, Quality Management, Regulations, Reimbursement, Risk, Security Compliance, Smartphones, State Laws and Regulations, Support Documentation, Time Management, Training/Teaching, Trend Analysis, Writing Skills
LOCATION
Parsippany-Troy Hills, NJ
POSTED
Today
Job PurposeThe 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 sufficiencyConduct comprehensive medical record reviews to validate principal diagnosis, secondary diagnoses, procedures, MCC/CC capture, and DRG assignment accuracyWrite clear, persuasive, evidence‑based appeal letters that incorporate clinical rationale, coding guidelines, and regulatory references to support the original DRGSubmit appeals within required timelines and track each case through all stages of the appeal lifecycle, including initial review, reconsideration, and final determinationMaintain detailed logs of downgrade cases, outcomes, appeal success rates, and turnaround times to support throughput monitoring, trend analysis, and performance reportingIdentify patterns in payer downgrades and escalate systemic issues or documentation vulnerabilities to leadershipCollaborate with internal teams and providers to clarify ambiguous documentation and ensure clinical specificityIdentify documentation gaps or inconsistencies and provide targeted feedback to improve provider documentation practicesParticipate in internal audits, retrospective reviews, and quality assurance processes related to DRG validation, coding accuracy, and documentation completenessAssist in developing or refining documentation templates, provider education materials, and query processes to support ongoing CDI improvementEnsure all coding and documentation practices align with CMS regulations, AHA Coding Clinic guidance, and organizational compliance policiesStay current on payer audit trends, regulatory updates, DRG methodology changes, and emerging risk areas that may impact DRG assignment or audit outcomesSupport compliance initiatives by identifying potential vulnerabilities and recommending corrective actions or process improvementsPartner with internal teams to resolve complex DRG issues and ensure alignment across departmentsParticipate in provider education sessions, meetings, and case reviews to promote accurate documentation and DRG integrityCommunicate effectively with leadership regarding trends, risks, and opportunities for improvement in documentation and coding practicesServe as a subject‑matter expert for DRG downgrade processes, providing guidance and support to internal teamsOther duties as assignedUse, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standardsUnderstand and comply with Information Security and HIPAA policies and procedures at all timesLimit viewing of PHI to the absolute minimum as necessary to perform assigned dutiesQualificationsBachelor’s degree in Nursing requiredMinimum of 3 years of experience in clinical documentation improvement role - adult acute care experience in medical/surgical, critical care, emergency, and/or PACU settingRN, CCDS and/or CDIP with CCS (CCS, CIC) certification requiredDemonstrated inpatient coding experience in an acute care settingPrior 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 SystemsAbility to interpret complex clinical documentation across multiple specialties.Proficiency with EMR systems, encoder tools (e.g., 3M, Optum) and CDI workflow and reporting toolsProficiency in Microsoft Office SuiteStrong interpersonal skills, ability to communicate well at all levels of the organizationStrong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analysesHigh level of integrity and dependability with a strong sense of urgency and results oriented Excellent written and verbal communication skills requiredWorking ConditionsAbility to work outside of normal business hours as neededMust possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposesPhysical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hearMental Demands: The employee must be able to follow directions, collaborate with others, and handle stressWork Environment: The noise level in the work environment is usually minimalMed-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

About the Company

M

Med-Metrix