Clinical Documentation Specialist and Medical Record Expert

4 days ago


Cleveland, Ohio, United States Cleveland Clinic Full time

We are seeking a skilled Clinical Documentation Specialist to join our team at the Cleveland Clinic, where you will play a vital role in ensuring the accuracy and completeness of patient medical records. As a key member of our clinical documentation team, you will work closely with healthcare providers to review and improve the documentation of patient care, ensuring that it reflects the highest standards of quality and safety.

The ideal candidate will have a minimum of five years of experience in clinical nursing, inpatient or outpatient coding, or clinical documentation integrity. A strong understanding of ICD-10-CM, CPT, HCC, and HCPCS coding principles is essential, as is the ability to interpret complex medical information and communicate effectively with healthcare teams. If you are a motivated and detail-oriented professional with a passion for improving patient care, we encourage you to apply for this exciting opportunity.

As a Clinical Documentation Specialist at the Cleveland Clinic, you will be part of a dynamic team that is dedicated to delivering exceptional patient care. You will work in a fast-paced environment, collaborating with healthcare providers, clinical documentation specialists, and other stakeholders to ensure that medical records are accurate, complete, and compliant with industry standards. Your role will involve:

  • Concurrent review and query of patient medical records to ensure accurate and complete documentation
  • Education and training of healthcare providers on optimal documentation practices
  • Maintenance of accurate and complete records of review and query activity within our clinical documentation improvement software
  • Collaboration with healthcare teams to improve patient care and outcomes

We offer a competitive salary of $40.90 per hour, with opportunities for professional growth and development. Our comprehensive benefits package includes health, dental, and vision insurance, as well as retirement savings options. If you are a skilled and motivated professional who is passionate about improving patient care, we encourage you to apply for this exciting opportunity.

At the Cleveland Clinic, we are committed to providing a supportive and inclusive work environment that fosters growth, development, and success. We offer a range of benefits and programs to support your physical and mental well-being, including access to on-site fitness centers, Employee Assistance Programs, and mental health resources. We also offer opportunities for professional development and growth, including training programs, mentorship, and career advancement opportunities.

Join our team and become a part of a dynamic and innovative organization that is dedicated to delivering exceptional patient care. Apply now to become a Clinical Documentation Specialist at the Cleveland Clinic and take the first step towards a rewarding and challenging career in clinical documentation and medical records.



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