CDI DRG Downgrade Specialist- Remote

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
• Affiliate with internal teams to develop or refine 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

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
• 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