Clinical Documentation Specialist I

Cleveland Clinic

4d • Remote

About The Position

The Clinical Documentation Specialist I 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 appropriate DRG, APC, and HCC assignment, severity of illness, and risk of mortality in alignment with industry compliance standards. The position works remotely on a day schedule from 8:00 a.m. to 5:00 p.m., supporting inpatient and outpatient documentation integrity activities.

Inpatient work includes determining principal and qualifying secondary diagnoses and relevant procedures, assigning working DRGs, querying and educating providers to improve diagnostic specificity and present-on-admission documentation, tracking reviews and queries in CDI software, meeting productivity targets, supporting other staff as needed, maintaining CEUs, advancing formal education toward ACDIS certification, and participating in clinical staff education.

Outpatient work includes reviewing records across provider offices, clinics, ambulatory surgery centers, and emergency departments; querying providers and medical team members to clarify documentation; applying clinical knowledge to assess how records translate into coded data; educating providers on documentation of disease processes, severity, complexity, and acuity; recording review and query activity in CDI software; meeting productivity targets; supporting other staff as needed; advancing education toward ACDIS certification; and contributing to education for physicians, advanced practice providers, and other clinical ancillary staff.

The work environment is a moderate-noise business office environment. The role requires following standard precautions and using personal protective equipment as required. Physical demands include standing, walking, sitting, lifting and carrying up to 25 pounds, close, distant, and color vision, and manual dexterity to handle records and operate a PC.

Requirements

• High school diploma/GED or equivalent.
• Five years of experience as a clinical nurse or inpatient/outpatient coder, or two years of experience as a Clinical Documentation Integrity Specialist.
• Proficiency using department CDI software.
• Ability to use reporting functions as needed to develop materials for meetings and presentations.

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.
• Strong medical-surgical, ICU, or ER background.
• PSI and CDI knowledge.
• Knowledge of physician documentation in an inpatient or outpatient setting.
• Knowledge of inpatient or outpatient payment methodologies.
• Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS within one year of hire.

Responsibilities

• Determine principal diagnosis, qualifying secondary diagnoses, and impacting procedures, and assign the appropriate working DRG for inpatient reviews.
• Query and educate providers to obtain diagnostic specificity and present-on-admission status that accurately reflect patient conditions.
• Adhere to industry standards for documentation and coding compliance.
• Maintain accurate and complete records of review and query activity in CDI software.
• 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.
• Provide guidance to CDS staff on processes, procedures, and coverage determinations as workload requires.
• Meet CEU requirements to maintain license and certification.
• Advance formal education and work toward ACDIS certification.
• Participate in education for physicians, advanced practice providers, and other clinical ancillary staff.
• Review medical records for patients in outpatient settings, including provider offices, physician- and hospital-owned clinics, ambulatory surgery centers, and emergency departments.
• Query providers and medical team members to clarify clinical documentation.
• Apply clinical knowledge to evaluate how medical records translate into coded data, including provider and clinical documentation, chronic disease processes, medications and indications, diagnostic information, and treatment plans.
• Educate providers on optimal documentation and disease-process identification to support accurate reflection of severity, complexity, and acuity and facilitate accurate coding and billing.

What This Job Offers

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