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-Finance

                      

Job Code

T99120

                     

Shift

Days

                       

Schedule

8:00am-4:00pm

                       

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.   

As a Clinical Documentation Specialist, you will provide education to providers and clinicians to ensure the documentation of all clinical conditions and procedures within the medical record accurately reflects the condition(s) and treatment(s) of patients. You will review for correct DRG, APC and HCC assignment, severity of illness and risk of mortality to align with industry standards regarding compliance. 

A caregiver in this role works remotely from 8:00 a.m. – 4:00 p.m.

Inpatient  

• Determine principal diagnosis, qualifying secondary diagnoses and impacting procedures and assign appropriate working DRG. 

• Query and educate providers to obtain the greatest possible diagnostic specificity and present on 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.   

• Meet daily review, query and query response targets.  

• Assist other caregivers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations. 

• Meet CEU requirements to maintain license and certification.  

• Advance formal education and work toward obtaining ACDIS certification.  

• Participate as needed in providing education to physicians, advanced practice providers and other clinical ancillary staff. 

• Other duties as assigned.

Outpatient 

• Conduct reviews of medical records for patients in a variety of outpatient settings, including provider offices, physician and hospital‐owned clinics, Ambulatory Surgery Centers (ASC) and Emergency Departments. 

• Query providers and medical team members caring for the patient to clarify clinical documentation. 

• Apply clinical knowledge to evaluate how the medical record will translate into coded data, including reviewing provider and other clinical documentation, chronic disease processes, medications and indications, diagnostic information and treatment plans. 

• Educate providers about optimal documentation and identification of disease processes to ensure proper reflection of severity of illness, complexity, and acuity and facilitate accurate coding and billing. 

• Maintain an accurate and complete record of review and query activity within 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.   

• Meet daily review, query and query response targets.  

• Assist other caregivers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations. 

• Advance formal education and work toward obtaining ACDIS Certification.  

• Participate as needed in providing education to physicians, advanced practice providers and other clinical ancillary staff.  

• Other duties as