DRG Downgrade Clinical Documentation Improvement - Revenue Integrity & Denials Management

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

Position Overview

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.

MINIMUM REQUIREMENTS
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
Knowledge and Skills:    • 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.
Mental, Behavioral and Emotional Abilities:    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  
Reporting Relationships
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.

ESSENTIAL FUNCTIONS
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

PHYSICAL DEMANDS AND WORK ENVIRONMENT
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
 

IND123.

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• 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

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.