Clinical Documentation Specialist I
Cleveland Clinic · Fort Lauderdale, FL · 1 mo ago
On-siteOTHR$63k/yrFull-time
We need to output HTML fragment with sections: About the role? The posting includes intro about Cleveland Clinic and role description. We need to use for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must include sections only when posting has real specific content. We have content: description of role (responsibilities) includes inpatient and outpatient duties. Also schedule: "A caregiver in this role works remotely from 8:00 a.m. – 4:00 p.m. (flexible start/end times)". That's schedule. Pay: we have Pay Range Minimum Annual Salary: $63,250.00 Maximum Annual Salary: $96,467.50. So we can include Pay section. Benefits: not explicitly listed; they mention benefits package but not specifics. So we should not create Benefits section because no specific benefits listed. Qualifications: we have Minimum qualifications and Preferred qualifications. Could combine into Requirements/Qualifications. The instruction: Use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). We need to decide which to use. Likely we need About the role (intro), Responsibilities (duties), Requirements (minimum qualifications), Qualifications (preferred qualifications), Pay, Schedule. Skills maybe not explicit. We'll include About the role, Responsibilities, Requirements, Qualifications, Pay, Schedule.
We must not repeat job title as heading. No Job ID. Remove boilerplate.
We need to preserve all substantive information. So we need to include all duties, qualifications, schedule, pay.
We must use
for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must include sections only when posting has real specific content. We have content: description of role (responsibilities) includes inpatient and outpatient duties. Also schedule: "A caregiver in this role works remotely from 8:00 a.m. – 4:00 p.m. (flexible start/end times)". That's schedule. Pay: we have Pay Range Minimum Annual Salary: $63,250.00 Maximum Annual Salary: $96,467.50. So we can include Pay section. Benefits: not explicitly listed; they mention benefits package but not specifics. So we should not create Benefits section because no specific benefits listed. Qualifications: we have Minimum qualifications and Preferred qualifications. Could combine into Requirements/Qualifications. The instruction: Use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). We need to decide which to use. Likely we need About the role (intro), Responsibilities (duties), Requirements (minimum qualifications), Qualifications (preferred qualifications), Pay, Schedule. Skills maybe not explicit. We'll include About the role, Responsibilities, Requirements, Qualifications, Pay, Schedule.
We must not repeat job title as heading. No Job ID. Remove boilerplate.
We need to preserve all substantive information. So we need to include all duties, qualifications, schedule, pay.
We must use - for any list of duties/requirements/benefits. For prose use
. So we need to convert lists into
- . For responsibilities we have many sentences; we can break into list items. For requirements (minimum qualifications) we have bullet-like sentences; we can list. For preferred qualifications similarly.
We need to ensure we don't invent or summarize away detail. Keep all details.
Let's extract content:
Intro: "Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world."
That's About the role.
Responsibilities: 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. Then Inpatient list of duties, then Outpatient list.
We need to capture all duties.
Let's list Inpatient duties:
- 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.
- Adhere to industry standards pertaining to documentation and coding compliance.
- 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.
- Meet CEU requirements to maintain license and certification.
- 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.
- Other duties as assigned.
Outpatient duties:
- 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.
- 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 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 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.
- Other duties as assigned.
Note some duplicates: meeting daily targets, assist other caregivers, advance formal education, participate in education, other duties as assigned appear in both sections. We should keep them but could deduplicate? The instruction: Preserve ALL substantive information; do NOT invent or summarize away detail. Duplicated lines: we should remove duplicated lines? It says "Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions." So we should remove duplicated lines. So we need to deduplicate identical sentences across inpatient and outpatient. Let's identify duplicates:
- "Meet daily review, query and query response targets." appears in both.
- "Assist other caregivers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations." appears in both.
- "Advance formal education and work toward obtaining ACDIS certification." (note outpatient says ACDIS Certification capital C) but essentially same.
- "Participate as needed in providing education to physicians, advanced practice providers and other clinical ancillary staff." appears both.
- "Other duties as assigned." appears both.
We should keep only one instance of each duplicate.
Now Minimum qualifications:
- 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
Preferred qualifications:
- Associate’s Degree in healthcare-related field
- Registered Nurse (RN) in the current state of employment
- ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience
- Clinical Documentation Specialist experience
- Experience in chart review or coding
- 5+ years of experience working as a floor nurse
- ICU or cardiac background
Also there is "Physical Requirements:" section with details. Should we include as a section? The allowed headings include Skills, Benefits, Pay, Schedule, etc. Physical Requirements could be under Requirements or maybe Skills? Not listed. Could we create a section "Physical Requirements"? Not in the list of allowed headings but we could treat as part of Requirements or Skills. The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It says e.g., not exhaustive but likely we should stick to those. Physical requirements could be placed under Requirements or Skills. Since it's about physical demands, maybe under Requirements. We'll include a - list under Requirements for physical requirements.
Also Personal Protective Equipment: "Follows standard precautions using personal protective equipment (PPE) as required." Could be under Requirements as well.
Now Pay: we have Pay Range Minimum Annual Salary: $63,250.00 Maximum Annual Salary: $96,467.50 plus description. We'll include Pay section with
containing that info.
Schedule: "A caregiver in this role works remotely from 8:00 a.m. – 4:00 p.m. (flexible start/end times)". We'll include Schedule section.
Now About the role: we have intro paragraph.
Now we need to output only HTML fragment, no /, no markdown.
Let's structure:
About the role
Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world.
Responsibilities
- 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.
- 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.
- Adhere to industry standards pertaining to documentation and coding compliance.
- 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.
- Meet CEU requirements to maintain license and certification.
- 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.
- 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.
- 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 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 to ensure completion of reviews in assigned areas and optimal selection of working MS DRG and APR DRG.
- Other duties as assigned.
Note we removed duplicates: we kept only one instance of Meet daily..., Assist..., Advance..., Participate..., Other duties...
We kept the inpatient and outpatient specific items.
Now Requirements section: include minimum qualifications and physical requirements and PPE.
We'll do:
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
- Physical demands require standing, walking, sitting, lifting, carrying up to 25 lbs.
- Close, distant, and color vision is required.
- Requires manual dexterity to grasp and handle records and to operate a PC in the course of work.
- The work environment is at a moderate noise level (business office with phones, copiers,
. So we need to convert lists into
- . For responsibilities we have many sentences; we can break into list items. For requirements (minimum qualifications) we have bullet-like sentences; we can list. For preferred qualifications similarly.
We need to ensure we don't invent or summarize away detail. Keep all details.
Let's extract content:
Intro: "Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world."
That's About the role.
Responsibilities: 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. Then Inpatient list of duties, then Outpatient list.
We need to capture all duties.
Let's list Inpatient duties:
- 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.
- Adhere to industry standards pertaining to documentation and coding compliance.
- 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.
- Meet CEU requirements to maintain license and certification.
- 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.
- Other duties as assigned.
Outpatient duties:
- 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.
- 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 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 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.
- Other duties as assigned.
Note some duplicates: meeting daily targets, assist other caregivers, advance formal education, participate in education, other duties as assigned appear in both sections. We should keep them but could deduplicate? The instruction: Preserve ALL substantive information; do NOT invent or summarize away detail. Duplicated lines: we should remove duplicated lines? It says "Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions." So we should remove duplicated lines. So we need to deduplicate identical sentences across inpatient and outpatient. Let's identify duplicates:
- "Meet daily review, query and query response targets." appears in both.
- "Assist other caregivers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations." appears in both.
- "Advance formal education and work toward obtaining ACDIS certification." (note outpatient says ACDIS Certification capital C) but essentially same.
- "Participate as needed in providing education to physicians, advanced practice providers and other clinical ancillary staff." appears both.
- "Other duties as assigned." appears both.
We should keep only one instance of each duplicate.
Now Minimum qualifications:
- 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
Preferred qualifications:
- Associate’s Degree in healthcare-related field
- Registered Nurse (RN) in the current state of employment
- ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience
- Clinical Documentation Specialist experience
- Experience in chart review or coding
- 5+ years of experience working as a floor nurse
- ICU or cardiac background
Also there is "Physical Requirements:" section with details. Should we include as a section? The allowed headings include Skills, Benefits, Pay, Schedule, etc. Physical Requirements could be under Requirements or maybe Skills? Not listed. Could we create a section "Physical Requirements"? Not in the list of allowed headings but we could treat as part of Requirements or Skills. The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It says e.g., not exhaustive but likely we should stick to those. Physical requirements could be placed under Requirements or Skills. Since it's about physical demands, maybe under Requirements. We'll include a
- list under Requirements for physical requirements.
Also Personal Protective Equipment: "Follows standard precautions using personal protective equipment (PPE) as required." Could be under Requirements as well.
Now Pay: we have Pay Range Minimum Annual Salary: $63,250.00 Maximum Annual Salary: $96,467.50 plus description. We'll include Pay section with
containing that info. Schedule: "A caregiver in this role works remotely from 8:00 a.m. – 4:00 p.m. (flexible start/end times)". We'll include Schedule section. Now About the role: we have intro paragraph. Now we need to output only HTML fragment, no /, no markdown. Let's structure:
About the role
Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world.
Responsibilities
- 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.
- 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.
- Adhere to industry standards pertaining to documentation and coding compliance.
- 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.
- Meet CEU requirements to maintain license and certification.
- 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.
- 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.
- 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 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 to ensure completion of reviews in assigned areas and optimal selection of working MS DRG and APR DRG.
- Other duties as assigned.
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
- Physical demands require standing, walking, sitting, lifting, carrying up to 25 lbs.
- Close, distant, and color vision is required.
- Requires manual dexterity to grasp and handle records and to operate a PC in the course of work.
- The work environment is at a moderate noise level (business office with phones, copiers,
- list under Requirements for physical requirements.
Also Personal Protective Equipment: "Follows standard precautions using personal protective equipment (PPE) as required." Could be under Requirements as well.
Now Pay: we have Pay Range Minimum Annual Salary: $63,250.00 Maximum Annual Salary: $96,467.50 plus description. We'll include Pay section with