Capital Health, a leading healthcare provider in the region, is seeking a DRG Downgrade Denial Specialist for full-time day shifts in Revenue Integrity & Denials Management.
This role is responsible for administrative management, tracking, and resolution coordination of DRG downgrade denials across all payers and third-party audit firms. The specialist will ensure cases are triaged, routed, documented, tracked, and submitted per payer and auditor requirements. The role collaborates with clinical resources to support successful appeals and denial prevention.
Key responsibilities include reviewing and triaging downgrade cases, routing to appropriate teams, maintaining accurate inventories with deadlines and statuses, coordinating medical record requests, ensuring compliance with requirements, follow-up activities, documenting clear notes, identifying downgrade trends, and supporting denial prevention initiatives.
The position requires strong organizational skills, attention to detail, root cause analysis ability, and strong written communication for documentation and coordination.
The weekly schedule is 40 hours, and usual workday is 8 hours.
Capital Health offers a comprehensive benefits package including medical, dental, vision, FSA, retirement savings plan, disability benefits, employee assistance program, commuter benefits, supplemental insurances, paid time off, and more.
- High school diploma or equivalent required; Associate or Bachelor's degree in healthcare or business preferred
- Three years' hospital billing, denials management, appeals coordination, or related revenue cycle experience
- Experience with DRG downgrades, payer audits, or post-payment reviews strongly preferred
- CCS credential required
- Working knowledge of DRG downgrade processes and third-party audit workflows
- Strong understanding of hospital billing systems and payer claim adjudication
- Ability to manage detailed tracking and documentation across appeal levels
- Strong organizational, analytical, and written communication skills
- Proficiency with Microsoft Office, including Excel
- Ability to meet deadlines, demonstrate good judgment, and be metric-driven
- Medical, Prescription drug coverage & In-House Employee Pharmacy
- Dental and Vision plans
- Flexible Spending Accounts (Healthcare and Dependent Care)
- Retirement Savings and Investment Plan
- Basic and Supplemental Life and AD&D Insurance
- Short and Long Term Disability
- Employee Assistance Program
- Commuter Transit and Parking
- Voluntary Life Insurance (Spouse, Employee, Child)
- Voluntary Legal Services
- Voluntary Accident, Critical Illness, Hospital Indemnity Insurance
- Voluntary Identity Theft and Pet Insurance
- Paid Time-Off Program
Location
New Jersey, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
1 week ago