Clinical Documentation Specialist

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Educate providers and clinicians to ensure that clinical conditions and procedures are accurately represented in medical records.

• Examine documentation for appropriate DRG, APC, and HCC assignments, as well as severity of illness and risk of mortality.

• Identify principal diagnoses, qualifying secondary diagnoses, relevant procedures, and the correct working DRG for inpatient cases.

• Engage with providers to obtain diagnostic specificity and present-on-admission status through queries and education.

• Comply with documentation and coding standards.

• Accurately record review and query activities in CDI software.

• Utilize CDI software tools to conduct reviews and enhance working MS DRG and APR DRG selection.

• Achieve daily targets for reviews, queries, and query responses.

• Offer guidance to CDS staff on processes, procedures, and coverage determinations.

• Participate in training sessions for physicians, advanced practice providers, and clinical ancillary staff.

• Conduct outpatient medical record reviews in provider offices, physician- and hospital-owned clinics, Ambulatory Surgery Centers, and Emergency Departments.

• Clarify clinical documentation by querying providers and members of the medical team.

• Apply clinical expertise to assess how records convert into coded data, including diagnoses, medications, diagnostics, and treatment plans.

• Educate providers on documentation and disease-process identification to promote accurate coding and billing.

⛳️ Requirements

• High School Diploma/GED or equivalent qualification.

• Five years of experience as a clinical nurse, inpatient or outpatient coder, OR two years as a Clinical Documentation Integrity Specialist.

• Associate’s Degree in a healthcare-related discipline is preferred.

• Current Registered Nurse (RN) license in the state of employment is preferred.

• Preferred experience in ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding.

• ICU experience is preferred.

• Strong surgical and CDI experience is preferred.

• Familiarity with EPIC, 3M, and Microsoft applications is preferred.

• Must meet CEU requirements to maintain license and certification.

• Ability to acquire ACDIS certification.

• Must be able to work remotely from 8:00 a.m. to 4:00 p.m.

• Physical capability to stand, walk, sit, lift, and carry up to 25 lbs.

• Ability to perceive close, distant, and color vision.

• Manual dexterity to manage records and operate a PC.

• Adhere to standard precautions and required personal protective equipment.

• Successful completion of controlled-substance testing post-employment offer.

• Compliance with the annual influenza prevention program or an approved exemption.

🏝️ Benefits

• Annual influenza vaccination or approved exemption in line with Cleveland Clinic Health System’s influenza prevention program.

• Equal opportunity employment in a drug-free environment.

• Support and appreciation from the Cleveland Clinic Health System.

• Opportunities for career development and formal education advancement.

• CEU support to maintain license and certification.