[Hiring] Clinical Documentation Specialist I @Cleveland Clinic

Role Description

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.

Outpatient:

• 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.

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

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
• Epic knowledge
• Technology savvy

Physical Requirements

• 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, computers, and printers).

Personal Protective Equipment

• Follows standard precautions using personal protective equipment (PPE) as required.