Clinical Documentation Specialist – I

🔥 0 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

🚫👨‍🎓 No degree required

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Cleveland Clinic

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Cleveland Clinic is a not-for-profit, multispecialty academic medical center located in Cleveland, Ohio. Founded in 1921, it integrates clinical and hospital care with research and education, earning a reputation as one of the largest and most respected hospitals in the country. The health system includes multiple facilities across Northeast Ohio and other locations globally, providing a wide range of specialized services such as cancer care, women's health, dermatology, and cardiovascular care. Cleveland Clinic is accredited by The Joint Commission, which underscores its commitment to high standards in healthcare delivery.

📋 Description

• Provide education to providers and clinicians so medical-record documentation accurately reflects patient conditions and treatments • Review documentation for correct DRG, APC, and HCC assignment, severity of illness, and risk of mortality • Determine principal diagnosis, qualifying secondary diagnoses, impacting procedures, and appropriate working DRG for inpatient cases • Query and educate providers to obtain diagnostic specificity and present-on-admission status • Adhere to documentation and coding compliance standards • Record review and query activity accurately in CDI software • Use CDI software tools to complete assigned reviews and optimize working MS DRG and APR DRG selection • Meet daily review, query, and query-response targets • Guide CDS staff regarding processes, procedures, and coverage determinations as workload requires • Meet CEU requirements and advance formal education toward ACDIS certification • Provide education to physicians, advanced practice providers, and clinical ancillary staff as needed • Review outpatient medical records across provider offices, clinics, ambulatory surgery centers, and emergency departments • Clarify clinical documentation by querying providers and medical team members • Evaluate how clinical documentation translates into coded data, including diseases, medications, diagnostics, and treatment plans • Educate providers on documentation and disease identification to support accurate coding and billing

🎯 Requirements

• High School Diploma/GED or equivalent • Five years of experience as clinical nurse, inpatient or outpatient coder OR two years of experience as a Clinical Documentation Integrity Specialist • Proficient in the use of department CDI software • Ability to utilize reporting functions to develop materials for meetings and presentations • Associate’s Degree in healthcare-related field preferred • Registered Nurse (RN) in the current state of employment preferred • ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience preferred • Strong Med Surg, ICU or ER background preferred • PSI and CDI knowledge preferred • Knowledge of physician documentation in the inpatient or outpatient setting preferred • Knowledge of inpatient or outpatient payment methodologies preferred • Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS within one year of hire preferred • Physical ability to stand, walk, sit, lift, and carry up to 25 lbs • Close, distant, and color vision required • Manual dexterity to handle records and operate a PC • Compliance with required PPE and annual influenza prevention program • Successful post-offer controlled-substance testing

🏖️ Benefits

• Endless support and appreciation • Annual influenza vaccination program or approved exemption • Drug-free workplace with post-offer controlled-substance testing • Equal employment opportunity