Cleveland Clinic Health System
healthcare
ClinicalDocumentationSpecialist
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“Clinical Documentation Specialist at Cleveland Clinic Health System. Skills: Clinical Documentation, Provider Education, Coding, Compliance. Provide education to providers and clinicians. Ensure documentation accurately reflects patient conditions”
What You'll Achieve.
Meet daily review, query and query response targets
Industry & Context.
Works in an environment where there is some discomfort due to dust, noise, temperature., Requires extensive walking, telephone use, bending, reaching, and lifting items weighing twenty pounds or less., Must be able to work well under pressure and maintain professional demeanor under adverse conditions., Extensive reading, writing, use of pagers, fax machines, computers, and copiers., Sedentary Work - Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body., Follows standard precautions using personal protective equipment as required, Must comply with influenza prevention program, including annual vaccination or approved exemption.
What They're Looking For.
Must Have
Five years of experience as clinical nurse, inpatient or outpatient coder, Two years of experience as a Clinical Documentation Integrity Specialist, High School Diploma/GED or equivalent
Nice to Have
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, Coding background, ACDIS certification
What You'll Do.
Provide education to providers and clinicians
Ensure documentation accurately reflects patient conditions
Review for correct DRG
APC and HCC assignment
Align with industry standards regarding compliance
Determine principal diagnosis and qualifying secondary diagnoses
Query and educate providers for diagnostic specificity
Adhere to industry standards for documentation
Maintain record of review and query activity
Utilize CDI software tools for reviews
query and response targets
Conduct reviews of medical records in outpatient settings
Query providers and medical team members
Apply clinical knowledge to evaluate medical record
Educate providers about optimal documentation
Ensure proper reflection of severity of illness
Facilitate accurate coding and billing
How You'll Work.
Team & Collaboration
Assist other caregivers and management as workload requires; Provide guidance to CDS staff regarding processes/procedures; Work alongside passionate caregivers
Communication Scope
Provide education to providers and clinicians; Query and educate providers; Educate providers about optimal documentation
Full Job Description
## At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. ## We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and ****The Power of Every One.**** ### Job Title Clinical Documentation Specialist I ### Location Cleveland ### Facility Remote Location ### Department Health Information Management-Cleveland Clinic Akron General ### Job Code T99120 ### Shift Days ### Schedule 8:00am-5:00pm ### Job Summary ### Job Details 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. 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 days from 8:00 a.m. – 5:00 p.m.** **Inpatient** * 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 soft
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