Clinical Documentation Specialist I

Cleveland Clinic Health System

Cleveland, Ohio, US
Fully remote
Review clinical documentation
Educate providers
Ensure accurate coding
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

Job Summary

  • 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)

Matching Summary

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.

Skills & Requirements

Must-have

  • review clinical documentation
  • educate providers
  • ensure accurate coding
  • medical record review
  • CDI software system

Nice-to-have

  • patient-first healthcare
  • transforming patient experience
  • support and appreciation
  • rewarding career

Key Requirements

  • High School Diploma/GED or equivalent
  • Five years of experience as clinical nurse, inpatient or outpatient coder
  • 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
  • Registered Nurse (RN)
  • 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

Work Rights

Not specified

Tailored Resume

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