Clinical Documentation Specialist

🔥 14 hours 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 to ensure clinical conditions and procedures are accurately documented in medical records • 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 reviews and optimize working MS DRG and APR DRG selection • Meet daily review, query, and query-response targets • Provide guidance to CDS staff regarding processes, procedures, and coverage determinations • Participate in education for physicians, advanced practice providers, and clinical ancillary staff • Conduct outpatient medical-record reviews across provider offices, physician- and hospital-owned clinics, Ambulatory Surgery Centers, and Emergency Departments • Clarify clinical documentation by querying providers and medical team members • Apply clinical knowledge to evaluate how records translate into coded data, including diagnoses, medications, diagnostics, and treatment plans • Educate providers on documentation and disease-process identification to support accurate coding and billing

🎯 Requirements

• High School Diploma/GED or equivalent • Five years of experience as a clinical nurse, inpatient or outpatient coder, OR two years of experience as a Clinical Documentation Integrity Specialist • Associate’s Degree in a 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 • ICU experience preferred • Surgical and strong CDI experience preferred • Experience with EPIC, 3M, and Microsoft preferred • Ability to meet CEU requirements to maintain license and certification • Ability to obtain ACDIS certification • Ability to work remotely from 8:00 a.m. to 4:00 p.m. • Ability to stand, walk, sit, lift, and carry up to 25 lbs. • Close, distant, and color vision • Manual dexterity to handle records and operate a PC • Compliance with standard precautions and required personal protective equipment • Successful controlled-substance testing after an offer of employment • Compliance with the annual influenza prevention program or an approved exemption

🏖️ Benefits

• Annual influenza vaccination or approved exemption under Cleveland Clinic Health System’s influenza prevention program • Equal opportunity employment in a drug-free environment • Support and appreciation from Cleveland Clinic Health System • Career development and formal education advancement opportunities • CEU support to maintain license and certification

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