Clinical Documentation Specialist I
About the role
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.
Responsibilities
- Determine principal diagnosis, qualifying secondary diagnoses and impacting procedures and assign appropriate working DRG.
- Query and educate providers to obtain the greatest possible diagnostic specificity and present on admission status to accurately reflect the patient’s condition.
- 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.
- Meet daily review, query and query response targets.
- Assist other caregivers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations.
- Advance formal education and work toward obtaining ACDIS certification.
- Participate as needed in providing education to physicians, advanced practice providers and other clinical ancillary staff.
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
- Proficient in the use of department CDI software
- Ability to utilize the reporting functions as needed to develop materials for meetings and presentations
Qualifications
- Associate’s Degree in healthcare-related field
- Registered Nurse (RN) in the current state of employment
- IDC10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience
- Strong Med Surg, ICU or ER background
- PSI and CDI knowledge
- Knowledge of physician documentation in the 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
Skills
- Close, distant, and color vision is required
- Manual dexterity to grasp and handle records and to operate a PC in the course of work
Benefits
The pay range displayed on this job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set and education. The pay range displayed does not include any applicable pay practices (e.g., shift differentials, overtime, etc.). The pay range does not include the value of Cleveland Clinic’s benefits package (e.g., healthcare, dental and vision benefits, retirement savings account contributions, etc.).