Clinical Documentation Specialist I – Neuro Expansion

Role Overview

• Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare.
• 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.
• Review for correct DRG, APC and HCC assignment, severity of illness and risk of mortality to align with industry standards regarding compliance.
• 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
• 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)
• ICU or Med/Surg experience (preferred)
• EPIC, 3M and Microsoft Office skills (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.