At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

                        

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

                                    

Job TitleClinical Documentation Specialist I

                        

LocationCleveland

                    

FacilityRemote Location

                     

DepartmentCDI-Finance

                      

Job CodeT99120

                     

ShiftDays

                       

Schedule8:00am-5:00am

                       

Job Summary

                         

Job Details

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.

                       

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 tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year.

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. 

Please review the Equal Employment Opportunity poster. 

                  

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities