Clinical Documentation Specialist I

Because its caregivers have been driving the future of healthcare – since 1921, Cleveland Clinic is consistently named among “One of the Nation's Top Hospitals” by leading publications such as U.S. News & World Report. Founded in Cleveland, Ohio by four renowned physicians with a vision of providing outstanding patient care based on the principles of cooperation, compassion and innovation, Cleveland Clinic has grown to become the world’s first integrated international health system. More than a century later, that system is home to more than 70,000 top-talent caregivers providing world-class care across 100+ areas of specialty from a network of award-winning (Magnet®, Pathway to Excellence®, Baby-Friendly®) facilities in Ohio and Florida. Because millions of patients each year trust one name for exceptional healthcare – Cleveland Clinic is here for you.

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building 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 remotely 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 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.