Clinical Documentation Specialist

🔥 1 hour ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Cleveland Clinic

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10,000+ employees

Cleveland Clinic, located in Cleveland, Ohio, is a not-for-profit, multispecialty academic medical center that integrates clinical and hospital care with research and education.

📋 Description

• 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. • Review for correct DRG, APC and HCC assignment, severity of illness and risk of mortality to align with industry standards regarding compliance. • 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.

🎯 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 • 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) • ICU or Med/Surg experience (preferred) • EPIC, 3M and Microsoft Office skills (preferred)

🏖️ Benefits

• We know that fully supporting our caregivers is what creates the best outcomes for our patients. • Our outstanding, comprehensive offerings are an investment in your health, well-being and future.