The RN DRG Downgrades Appeals Review Specialist is responsible for the retrospective clinical review and defense of inpatient DRG downgrades, clinical validation denials, and medical necessity determinations issued by governmental and commercial payers.
JOB DUTIES AND RESPONSIBILITIES:
Conduct retrospective clinical record reviews to evaluate DRG downgrades, clinical validation denials, and medical necessity determinations.
Analyze documentation in conjunction with MS-DRG logic and ICD-10-CM/PCS coding guidelines to determine appeal opportunity.
Develop and submit defensible first- and second-level appeal letters using clinical evidence, regulatory guidance, coding standards, and payer policy.
Collaborate with Physician Advisors, Coding leadership, and CDI to support higher-level appeals (e.g., IRO, ALJ, payer conferences).
Identify denial trends and provide structured feedback to Coding and CDI leadership to reduce future payer vulnerability.
Participate in payer audit response processes (RAC, QIO, MIC, commercial auditors) and assist in preparation for formal appeal proceedings.
Maintain accurate documentation within EPIC, payer audit platforms, and internal tracking tools to support reporting and performance monitoring.
Review denial data and appeal outcomes to assist leadership in assessing revenue impact, case resolution trends, and operational improvement opportunities.
Maintain current knowledge of MS-DRG methodology, ICD-10-CM/PCS coding guidelines, clinical validation standards, federal and commercial payer policies, and medical necessity criteria.
Serve as a clinical resource regarding documentation specificity and disease process validation as it relates to reimbursement defense.
PHYSICAL AND SENSORY REQUIREMENTS:
Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation.
EDUCATION:
Registered Nurse required. BSN preferred. Active RN license required. CDI certification (CDIP, CCDS) preferred.
TRAINING AND EXPERIENCE:
Minimum five (5) years RN experience in adult inpatient acute care (medical/surgical or critical care). Strongly preferred: Clinical Documentation Improvement (CDI) experience. Strongly preferred: DRG downgrade or clinical validation denial experience. Strongly preferred: Utilization review or payer medical review experience. Familiarity with MS-DRG reimbursement methodology. Demonstrated understanding of disease pathophysiology and documentation specificity requirements. Working knowledge of ICD-10-CM/PCS fundamentals. Understanding of payer audit and appeal processes. Experience with EPIC and encoder tools (e.g., 3M) preferred.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!