Clinical Documentation Specialist I

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

As a Clinical Documentation Specialist, you will provide concurrent and retrospective review of the medical record to ensure the documentation of all conditions and procedures accurately reflect treatment, DRG or APC/HCC assignment, severity of illness, risk of mortality and quality measures. You will also serve as a one-on-one educator to physicians and clinicians to assist in fulfilling this goal. Additionally, this position offers numerous professional and personal development opportunities, helping you advance the Professional Ladder within the Cleveland Clinic Enterprise.

A caregiver in this role works remotely from 7:00 a.m. – 3:30 p.m.

A caregiver who excels in this role will:

• Conduct review of medical records for patients in a variety of outpatient settings, including provider offices, physician and hospital‐owned clinics, Ambulatory Surgery Centers 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 their 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 system to ensure completion of reviews.
• Participates in providing education to clinical team as needed.

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
• Understanding of risk adjusted payment methodologies, HCC assignment and payment methodology, professional coding and billing, outpatient facility coding and billing, APC assignment and OPPS reimbursement methodology

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
• Experienced nurse with over five years inpatient floor experience (ICU or Cardiac)
• Experience in chart review or coding

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Physical Requirements:

• Physical demands require standing, walking, sitting, lifting, one-third (or more) of the time.
• This position requires carrying or wheeling 10-25 pounds.
• PC/CRT skills are required one-fourth of the time.
• Close vision is required, typical physical demands require reading handwritten notes on busy inpatient nursing units.
• Requires manual dexterity to grasp and handle records and to operate a PC computer in the course of work.
• The work environment is at a moderate noise level (hospital/nursing unit). Ability to work under stress and meet deadlines.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment as required for procedures.

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.