DRG Downgrade Clinical Documentation Improvement - FT - Day - Revenue Integrity & Denials Mgmt Lawrenceville NJ

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

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

Benefits

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)
• Healthcare FSA
• Dependent Care FSA
• Retail 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 Life
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program