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!!
St. Luke's University Health Network is a regional network of hospitals, physicians and other related organizations providing care primarily in Lehigh, Northampton, Monroe, Carbon, Schuylkill, Bucks, Montgomery and Berks counties in Pennsylvania and Warren County in New Jersey.
The Network provides services at more than 150 sites. St. Luke's University Health Network is comprised of six hospital sites. The Network includes:
Areas of exceptional medical expertise include:
St. Luke's offers an exceptional benefit plan for employees. Our values are reflected in all we do for patients, each other and the community:
Pride - We take pride in our accomplishments and in our organization.
Caring - We show consideration for others and their feelings. We treat others as we want to be treated.
Respect - We recognize the value, diversity and importance of each other, those we serve and the organization.
Accountability - We are responsible to make decisions and solve problems in a timely and effective manner.
Flexibility - We adapt to the changing needs and expectations of those we serve.
Teamwork - We work together to improve quality.
The mission of St. Luke's University Health Network is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.