Clinical Documentation Integrity Specialist I

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building 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 position works remotely from 7:00AM - 3:30PM.

A caregiver who excels in this role will:   

Inpatient Clinical Documentation Specialist: 

• Determine principal diagnosis, qualifying secondary diagnoses and impacting procedures and assign appropriate working DRG. 
• Query and educate providers to obtain greatest possible diagnostic specificity. 
• Maintain an accurate and complete record of review and query activity in the CDI software system.  
• Utilize tools available in CDI software to ensure completion of reviews in assigned areas and optimal selection of working MS DRG and APR DRG.  
• Participate in department performance improvement and employee engagement activities.  
• Participate in providing education to physicians, Advanced Practice Providers and other clinical ancillary staff as needed. 

Outpatient Clinical Documentation Specialist: 

• 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 
• Current licensure as a Registered Nurse (RN) 
• Five years of experience as RN, inpatient/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 
• ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience 

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/