Clinical Documentation Specialist I – Neuro Expansion
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Job Description
Clinical Documentation Specialist providing patient-first healthcare at Cleveland Clinic. Educating providers to ensure accurate documentation and conducting reviews of medical records in various outpatient settings.
Responsibilities:
- Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare.
- 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.
- Review for correct DRG, APC and HCC assignment, severity of illness and risk of mortality to align with industry standards regarding compliance.
- 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.
- 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.
Requirements:
- 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
- Associate’s Degree in healthcare-related field (preferred)
- Registered Nurse (RN) in the current state of employment (preferred)
- ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience (preferred)
- ICU or Med/Surg experience (preferred)
- EPIC, 3M and Microsoft Office skills (preferred)
Benefits:
- We know that fully supporting our caregivers is what creates the best outcomes for our patients. Our outstanding, comprehensive offerings are an investment in your health, well-being and future.
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