Clinical Documentation Specialist I Job at Cleveland Clinic, Cleveland, OH

YXhlK20vN2VqMzY4V1ZtL2sxaFgvb1k9
  • Cleveland Clinic
  • Cleveland, OH

Job Description

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

This role supports value-based care and care of our patients. The Clinical Documentation Specialist will support providers and ensure strong documentation and compliant queries. This role helps the providers with chart reviews prior to the patients being seen. Our department goal is focused on risk adjustment, coding, and provider education.

A caregiver in this position works remotely from 8:00AM – 5:00PM.

A caregiver who excels in this role will:

Inpatient Clinical Documentation Specialist:

  • Determine principal diagnosis, qualifying secondary diagnoses and impacting procedures based on a review of the existing medical record.
  • Assign appropriate working DRG.
  • Query and educate providers to obtain greatest possible diagnostic specificity and present 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.
  • Become proficient in the use of new technology as it is deployed.
  • Meet daily review, query and query response targets.
  • Participate in department performance improvement and employee engagement activities.
  • Assist co-caregivers and management by providing guidance to CDS staff regarding processes/procedures and coverage determinations.
  • Participate in department sponsored educational opportunities and meet hospital specific educational requirements.
  • Meet CEU requirements to maintain license and certification.
  • Be encouraged to advance formal education and work toward ACDIS certification.
  • Participate as needed in providing 1:1 education to physicians, advanced practice providers and other clinical ancillary staff.

Minimum qualifications for the ideal future caregiver include:

  • High School Diploma/GED or equivalent
  • Five years of experience as clinical nurse in a high acuity department OR five years of experience as an inpatient or outpatient coder OR two years of experience as a Clinical Documentation Integrity Specialist

Preferred qualifications for the ideal future caregiver include:

  • 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

Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we’re dedicated to providing what matters most to you:

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.

Pay Range

Minimum hourly: $30.41

Maximum hourly: $46.38

The pay range displayed on this job posting reflects the anticipated range for new hires. While the pay range is displayed as an hourly rate, Cleveland Clinic recruiters will clarify whether the compensation is hourly or salary. A successful candidate's actual compensation will be determined after taking factors into consideration such as the candidate's work history, experience, skill set, and education. This is not inclusive of the value of Cleveland Clinic's benefits package, which includes among other benefits, healthcare/dental/vision and retirement.

Job Tags

Hourly pay, Work at office,

Similar Jobs

Carter Lumber

Delivery Driver - CDL Class A/B Job at Carter Lumber

 ...core values and our people-first culture remain the same. Description: As one of our CDL Delivery Specialists, you will be responsible for transporting orders to local customer jobsites in a safe and timely manner using our well-maintained and company-owned... 

SQRL

Clinical Research Associate Job at SQRL

 ...CLINICAL RESEARCH ASSOCIATE (PHASE 1 ONSITE, ONCOLOGY FOCUS) Salary: $100,000$130,000 + Full Benefits HIGHLIGHTS Onsite role at an actively expanding research site in Gainesville, GA Focus on Phase I clinical trials, with oncology as a key growth area... 

MedPro Healthcare Staffing

Travel Wound Care Nurse (RN) - $2,078 per week Job at MedPro Healthcare Staffing

 ...MedPro Healthcare Staffing is seeking a travel nurse RN Wound Care for a travel nursing job in Silver Spring, Maryland. Job Description & Requirements ~ Specialty: Wound Care ~ Discipline: RN ~ Start Date: 07/14/2025~ Duration: 13 weeks ~40 hours per week... 

Flex Workforce Solutions

PLC Programmer Job at Flex Workforce Solutions

 ...Job Description Job Description PLC/HMI Programmer Automation & Controls Engineering Join a dynamic engineering team delivering innovative automation solutions to diverse industrial and commercial clients . The PLC/HMI Programmer plays a critical role in... 

STRS Ohio

Web Designer/Front-End Web Developer Job at STRS Ohio

Join to apply for the Web Designer/Front-End Web Developer role at STRS OhioJoin to apply for...  ...to describe the general nature and level of work performed by persons assigned to...  ...applicable laws.Seniority level Seniority level Entry levelEmployment type Employment type...