Clinical Documentation Specialist I

                    

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

                        

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

                                    

Job Title

Clinical Documentation Specialist I

                        

Location

Cleveland

                    

Facility

Remote Location

                     

Department

Cdi Admin-Finance

                      

Job Code

T99120

                     

Shift

Days

                       

Schedule

8:00am-5:00pm

                       

Job Summary

                         

Job Details

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world.   

This role supports value-based care and care of our patients. As a Inpatient Clinical Documentation Specialist, you will provide education to providers and clinicians to ensure that the documentation of all clinical conditions and procedures within the medical record accurately reflects the patient’s condition(s) and treatment(s). By applying Clinical Documentation Improvement (CDI) principles and collaborating with providers, you will support appropriate coding, quality measure reporting, and reimbursement, while accurately reflecting patient severity of illness and risk of mortality.

A caregiver in this role works remotely from 8:00 a.m. – 5:00 p.m.

Shifts may start as early as 5:00 a.m. EST.

A caregiver who excels in this role will:

• Determine principal diagnosis, qualifying secondary diagnoses and impacting procedures based on a review of the existing medical record. 
• Assign appropriate working DRG. 
• Query and educate providers to obtain greatest possible diagnostic specificity and present admission status to accurately reflect the patient’s condition. 
• Adhere to industry standards pertaining to documentation and coding compliance. 
• Maintain an accurate and complete record of review and query activity in the CDI software system. 
• Utilize tools available in CDI software to ensure completion of reviews in assigned areas and optimal selection of working MS DRG and APR DRG. 
• Become proficient in the use of new technology as it is deployed. 
• Meet daily review, query and query response targets. 
• Participate in department performance improvement and employee engagement activities. 
• Assist co-caregivers and management by providing guidance to CDS staff regarding processes/procedures and coverage determinations. 
• Participate in department sponsored educational opportunities and meet hospital specific educational requirements. 
• Meet CEU requirements to maintain license and certification. 
• Be encouraged to advance formal education and work toward ACDIS certification. 
• Participate as needed in providing 1:1 education to physicians, advanced practice providers and other clinical ancillary staff. 

Minimum qualifications for the ideal future caregiver include:

• High School Diploma/GED or equivalent 
• Five years of experience as clinical nurse in a high acuity department OR five years of experience as an inpatient or outpatient coder OR two years of experience as a Clinical Documentation Integrity Specialist 

Preferred qualifications for the ideal future caregiver include:  

• Associate’s Degree in healthcare-related field 
• Registered Nurse (RN) in the current state of employment 
• ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience 
• ER, med surg, inpatient or care management experience

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/

Physical Requirements:

• Physical demands require standing, walking, sitting, lifting, carrying up to 25 lbs.
• Close, dista