Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist providing documentation education and compliance review for Cleveland Clinic's healthcare system. Ensuring accurate medical records and coding in patient care processes.
Responsibilities:
- Provide education to providers and clinicians for accurate clinical documentation
- Review for correct DRG, APC, and HCC assignment
- Adhere to industry standards for documentation and coding compliance
- Maintain a record of review and query activity in CDI software
- Conduct reviews of medical records in outpatient settings
- Educate providers on optimal documentation and coding
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)
Benefits:
- Endless support and appreciation
- Build a rewarding career
- Comply with influenza prevention program
- Equal opportunity employer
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