DRG Downgrade Denial Specialist - Revenue Integrity & Denials Mgmt

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:

$20.10 - $26.13

Scheduled Weekly Hours:

40

Position Overview

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.

MINIMUM REQUIREMENTS
Education:    High school diploma or equivalent required. Associate or bachelor’s degree in healthcare or business-related field preferred.
Experience:    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.
Other Credentials:    CCS
Knowledge and Skills:    • 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
Special Training:    Proficiency with Microsoft Office applications, including Excel.
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 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

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.