Clinical Documentation Specialist I

Cleveland Clinic

4d • Remote

About The Position

The Clinical Documentation Specialist provides education to providers and clinicians to ensure that documentation of clinical conditions and procedures in the medical record accurately reflects patients’ conditions and treatments. The role reviews documentation for correct DRG, APC, and HCC assignment, severity of illness, and risk of mortality in alignment with industry compliance standards. This position works remotely on a day schedule from 8:00 a.m. to 4:00 p.m.

For inpatient work, the specialist determines the principal diagnosis, qualifying secondary diagnoses, and relevant procedures, and assigns an appropriate working DRG. The specialist queries and educates providers to obtain diagnostic specificity and present-on-admission status, maintains review and query records in CDI software, uses available tools to complete reviews and select working MS DRG and APR DRG, and meets daily review, query, and response targets.

For outpatient work, the specialist reviews records from provider offices, clinics, Ambulatory Surgery Centers, and Emergency Departments. The role clarifies documentation with providers and medical team members, evaluates how clinical records translate into coded data, and educates providers on documentation that accurately reflects severity, complexity, and acuity and supports accurate coding and billing. The specialist also maintains CDI software records, meets productivity targets, assists colleagues and management with guidance and coverage as needed, participates in clinical staff education, and advances formal education and ACDIS certification.

Requirements

• High school diploma, GED, or equivalent.
• Five years of experience as a clinical nurse or inpatient or outpatient coder, or two years of experience as a Clinical Documentation Integrity Specialist.

Nice To Haves

• Associate’s degree in a healthcare-related field.
• Registered Nurse (RN) license in the current state of employment.
• ICD-10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience.
• ICU experience.
• Surgical and strong CDI experience.
• Experience with EPIC, 3M, and Microsoft systems.

Responsibilities

• Determine the principal diagnosis, qualifying secondary diagnoses, and impacting procedures, and assign an appropriate working DRG.
• Query and educate providers to obtain diagnostic specificity and present-on-admission status that accurately reflect the patient’s condition.
• Review outpatient medical records from provider offices, clinics, Ambulatory Surgery Centers, and Emergency Departments.
• Query providers and medical team members to clarify clinical documentation.
• Evaluate how medical record documentation translates into coded data, including provider and clinical documentation, chronic diseases, medications and indications, diagnostic information, and treatment plans.
• Educate providers about optimal documentation and identification of disease processes to reflect severity of illness, complexity, and acuity and facilitate accurate coding and billing.
• Adhere to industry standards for documentation and coding compliance.
• Maintain accurate and complete records of review and query activity in the CDI software system.
• Use CDI software tools to complete reviews in assigned areas and optimize selection of working MS DRG and APR DRG.
• Meet daily review, query, and query-response targets.
• Assist caregivers and management as workload requires by providing CDS staff guidance on 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 education for physicians, advanced practice providers, and other clinical ancillary staff.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED