Clinical Documentation Specialist I

Role Overview

• Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare.
• As a Clinical Documentation Specialist, you will provide education to providers and clinicians to ensure the documentation of all clinical conditions and procedures within the medical record accurately reflects the condition(s) and treatment(s) of patients.
• You will review for correct DRG, APC and HCC assignment, severity of illness and risk of mortality to align with industry standards regarding compliance.
• A caregiver in this role works remotely from 8:00 a.m. – 4:00 p.m. (flexible start/end times)
• Conduct reviews of medical records for patients in a variety of outpatient settings, including provider offices, physician and hospital‐owned clinics, Ambulatory Surgery Centers (ASC) and Emergency Departments.
• Query providers and medical team members caring for the patient to clarify clinical documentation.
• 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.

Requirements

• High School Diploma/GED or equivalent
• Five years of experience as clinical nurse, 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
• Associate’s Degree in healthcare-related field (preferred)
• Registered Nurse (RN) in the current state of employment (preferred)
• ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience (preferred)
• Clinical Documentation Specialist experience (preferred)
• Experience in chart review or coding (preferred)
• 5+ years of experience working as a floor nurse (preferred)

Benefits

• We know that fully supporting our caregivers is what creates the best outcomes for our patients.
• Our outstanding, comprehensive offerings are an investment in your health, well-being and future.