Clinical Documentation Specialist I

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building 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. – 5:00 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. 

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.  

Minimum qualifications for the ideal future caregiver include:

• 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 the reporting functions as needed to develop materials for meetings and presentations

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 

• Strong Med Surg, ICU or ER background

• PSI and CDI knowledge

• Knowledge of physician documentation in the inpatient or outpatient setting

• Knowledge of inpatient or outpatient payment methodologies

• Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS within one year of hire

Physical Requirements:

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

• Close, distant, and color vision is required.

• Requires manual dexterity to grasp and handle records and to operate a PC in the course of work.

• The work environment is at a moderate noise level (business office with phones, copiers, computers, and printers).

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment (PPE) as required.

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster. 

Cleveland Clinic is pleased to be an equal employment opportunity employer.