Cleveland Clinic Health System
healthcare
ClinicalDocumentationSpecialist
Neural analysis suggests this role is
optimal for Mid candidates.
“Clinical Documentation Specialist at Cleveland Clinic Health System. Skills: Clinical Documentation, Provider Education, Coding, Compliance. Provide education to providers and clinicians. Ensure documentation accuracy”
What You'll Achieve.
Ensure documentation accurately reflects patient condition; Accurately reflect severity of illness, complexity, and acuity; Facilitate accurate coding and billing; Meet daily review, query and query response targets
Industry & Context.
Works in an environment where there is some discomfort, Requires extensive walking, telephone use, bending, reaching, and lifting, Must be able to work well under pressure, Maintain professional demeanor under adverse conditions, Extensive reading, writing, use of pagers, fax machines, computers, and copiers, Sedentary Work, Follows standard precautions using personal protective equipment, Obtain an influenza vaccination on an annual basis or obtain an 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 accuracy
Review for correct DRG
APC and HCC assignment
Align with industry standards
Conduct reviews of medical records
Query providers and medical team members
Apply clinical knowledge to evaluate medical record
Educate providers about optimal documentation
How You'll Work.
Team & Collaboration
Assist other caregivers and management; Provide guidance to CDS staff
Communication Scope
Education to providers; Query providers
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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