Clinical Documentation Specialist I

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

This role supports value-based care and care of our patients. The Clinical Documentation Specialist will support providers and ensure strong documentation and compliant queries. This role helps the providers with chart reviews prior to the patients being seen. Our department goal is focused on risk adjustment, coding, and provider education.

A caregiver in this position works remotely from 8:00AM – 5:00PM.

A caregiver who excels in this role will:

Inpatient Clinical Documentation Specialist:

• Determine principal diagnosis, qualifying secondary diagnoses and impacting procedures based on a review of the existing medical record.
• Assign appropriate working DRG.
• Query and educate providers to obtain greatest possible diagnostic specificity and present 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.
• Become proficient in the use of new technology as it is deployed.
• Meet daily review, query and query response targets.
• Participate in department performance improvement and employee engagement activities.
• Assist co-caregivers and management by providing guidance to CDS staff regarding processes/procedures and coverage determinations.
• Participate in department sponsored educational opportunities and meet hospital specific educational requirements.
• Meet CEU requirements to maintain license and certification.
• Be encouraged to advance formal education and work toward ACDIS certification.
• Participate as needed in providing 1:1 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 in a high acuity department OR five years of experience as an inpatient or outpatient coder OR two years of experience as a Clinical Documentation Integrity Specialist
  
  

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
  
  

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/

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.
  
  

Pay Range

Minimum hourly: $30.41

Maximum hourly: $46.38

The pay range displayed on this job posting reflects the anticipated range for new hires. While the pay range is displayed as an hourly rate, Cleveland Clinic recruiters will clarify whether the compensation is hourly or salary. A successful candidate's actual compensation will be determined after taking factors into consideration such as the candidate's work history, experience, skill set, and education. This is not inclusive of the value of Cleveland Clinic's benefits package, which includes among other benefits, healthcare/dental/vision and retirement.