Job Purpose The 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 sufficiency
- Conduct comprehensive medical record reviews to validate principal diagnosis, secondary diagnoses, procedures, MCC/CC capture, and DRG assignment accuracy
- Write clear, persuasive, evidence based appeal letters that incorporate clinical rationale, coding guidelines, and regulatory references to support the original DRG
- Submit appeals within required timelines and track each case through all stages of the appeal lifecycle, including initial review, reconsideration, and final determination
- Maintain detailed logs of downgrade cases, outcomes, appeal success rates, and turnaround times to support throughput monitoring, trend analysis, and performance reporting
- Identify patterns in payer downgrades and escalate systemic issues or documentation vulnerabilities to leadership
- Collaborate with internal teams and providers to clarify ambiguous documentation and ensure clinical specificity
- Identify documentation gaps or inconsistencies and provide targeted feedback to improve provider documentation practices
- Participate in internal audits, retrospective reviews, and quality assurance processes related to DRG validation, coding accuracy, and documentation completeness
- Assist in developing or refining documentation templates, provider education materials, and query processes to support ongoing CDI improvement
- Ensure all coding and documentation practices align with CMS regulations, AHA Coding Clinic guidance, and organizational compliance policies
- Stay current on payer audit trends, regulatory updates, DRG methodology changes, and emerging risk areas that may impact DRG assignment or audit outcomes
- Support compliance initiatives by identifying potential vulnerabilities and recommending corrective actions or process improvements
- Partner with internal teams to resolve complex DRG issues and ensure alignment across departments
- Participate in provider education sessions, meetings, and case reviews to promote accurate documentation and DRG integrity
- Communicate effectively with leadership regarding trends, risks, and opportunities for improvement in documentation and coding practices
- Serve as a subject matter expert for DRG downgrade processes, providing guidance and support to internal teams
- Other duties as assigned
- Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
- Understand and comply with Information Security and HIPAA policies and procedures at all times
- Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties
Qualifications
- Bachelor’s degree in Nursing required
- Minimum of 3 years of experience in an inpatient clinical documentation improvement role
- Minimum of 5 years nursing experience in adult acute care in medical/surgical, critical care, emergency, and/or PACU setting
- RN license required
- CCDS and/or CDIP required
- CCS or CIC certification required
- Demonstrated inpatient coding experience in an acute care setting
- Prior 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 Systems
- Ability to interpret complex clinical documentation across multiple specialties.
- Proficiency with EMR systems, encoder tools (e.g., 3M, Optum) and CDI workflow and reporting tools
- Proficiency in Microsoft Office Suite
- Strong interpersonal skills, ability to communicate well at all levels of the organization
- Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
- High level of integrity and dependability with a strong sense of urgency and results oriented
- Excellent written and verbal communication skills required
Working Conditions
- Ability to work outside of normal business hours as needed
- Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes
- Physical 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 hear
- Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
- Work Environment: The noise level in the work environment is usually minimal
Med-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.
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