Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as the No. 4 hospital in the nation, according to the U.S. and World News Report. At Cleveland Clinic, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world. Previous CDI experience strongly preferred.

As a remote Clinical Documentation Specialist I, you’ll play an essential role in processing and organizing patient information. As part of your responsibilities, you will:

• Perform regular chart reviews.

• Query inpatient encounters to determine principal diagnosis, qualify secondary diagnoses and qualify procedures to assign the appropriate working DRG.

• Ensure that documentation reflects the appropriate DRG assignment or APC and HCC assignment, severity of illness, risk of mortality, and quality measures.

• Coordinate provider educations, and adheres to industry standards pertaining to compliance.

The ideal candidate:

• Can work remotely while collaborating with other members of the CDI team.

• Communicates clearly with caregivers.

• Has medical/surgical or critical care experience.

• Is detail oriented and works toward continuous improvement.

Specialists may grow into other roles within the organization, such as Clinical Documentation Specialist II, QEC, Supervisor or Manager. You can also take advantage of continuing education and mentoring opportunities.

Cleveland Clinic provides what matters most: career growth, delivering world-class care to our patients, continuous learning, exceptional benefits and working for an organization that offers many long-term career paths. Join us and experience a culture where opportunities to advance and the support to get there go hand in hand.

Responsibilities:

Inpatient Clinical Documentation Specialist:

• Concurrent review/query process: Based on review of the existing medical record, determines principal diagnosis, qualifying secondary diagnoses, impacting procedures and assigns appropriate working DRG.
• Queries and educates providers to obtain greatest possible diagnostic specificity, and present on admission status, to accurately reflect the patient’s condition. Adheres to industry standards pertaining to documentation and coding compliance.
• Optimal use of Clinical Documentation Improvement (CDI) software: Maintains an accurate and complete record of review and query activity in the CDI software system. Utilizes tools available in CDI software to ensure completion of reviews in assigned areas, and optimal selection of working MS DRG and APR DRG. Becomes proficient in the use of new technology as it is deployed.
• Consistently maintains quality and productivity standards: Meets daily review, query and query response targets. Participates in department performance improvement and employee engagement activities. Assist co-caregivers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations.
• Professional development: Participates in department sponsored educational opportunities. Meets hospital specific educational requirements. Takes responsibility for own learning through reading professional journals and attending seminars. Meets CEU requirements to maintain license and certification. Encouraged to advance formal education and work toward obtaining ACDIS certification. Participates as needed in providing 1:1 educations to physicians, advanced practice providers and other clinical ancillary staff.
• Other duties and assigned.

Outpatient Clinical Documentation Specialist:

• Concurrent review/query process: Conduct reviews of medical records for patients in a variety of outpatient settings including but not limited to provider offices, physician and hospital‐owned clinics, ambulatory surgery centers, and hospital emergency departments.
• Queries providers and medical team members caring for the patient to clarify clinical documentation. Apply their 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 their 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.
• Understand risk adjusted payment methodologies, HCC assignment and payment methodology, professional coding and billing, outpatient facility coding and billing, APC assignment, and OPPS reimbursement methodology and share this knowledge with providers and members of the clinical team.
• Optimal use of clinical documentation improvement software: Maintains an accurate and complete record of review and query activity within the CDI software system. Utilizes tools available in CDI software system to ensure completion of reviews. Becomes proficient in the use of new technology as it is deployed.
• Consistently maintains quality and productivity standards: Meets daily review, query and query response targets. Participates in department performance improvement and employee engagement activities. Assists co-workers and management as workload requires by providing guidance to clinical documentation improvement staff regarding efficient processes/procedures and coverage determinations.
• Professional development: Participates in department sponsored educational opportunities. Meets hospital specific educational requirements. Takes responsibility for own learning through reading professional journals and attending webinars/seminars. Meets CEU requirements to maintain license and certifications. Encouraged to advance formal education and work toward ACDIS certification. Participates as needed in providing 1:1 education to clinical team (physicians, advanced practice providers, and ancillary staff).
• Other duties as assigned.

Education:

• High School Diploma/GED or equivalent required.
• Associate’s degree in healthcare related field preferred.

Certifications:

• Registered Nurse (RN) in the current state of employment preferred.

Complexity of Work:

• All employees are expected to meet the standards of performance outlined in the Organizational-Wide Competencies listed below as applied to the position:
• World Class Service Orientation: Includes attitude, behavior, interpersonal skill, and problem solving that enable an employee to respond to internal and external customer needs and expectations in a positive manner.
• Adaptability: Includes teamwork and flexibility needed to fulfill job responsibilities including adapting to changes in work environment and accepting supervisory feedback.
• Efficiency and Effectiveness: Includes quantity and quality of desired work, as well as organization skills necessary to perform successfully.
• Essential Job Requirements: Includes adherence to all relevant policies, procedures, and guidelines affecting the work environment, including maintenance of required competencies and communication skills.
• Supervisory Responsibilities (if applicable): Includes overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.
• Note: The above stated duties are intended to outline those functions typically performed by individuals assigned to this classification. This description of duties is not intended to be all inclusive nor to limit the discretionary authority of supervisors to assign other tasks of similar nature or level of responsibility.
• Thorough and up-to-date clinical skills.
• Excellent written and verbal communication skills required.
• Ability to write inquiries to physicians.
• Ability to effectively communicate with physicians to relay and obtain information as well as respond to questions.
• Assertive personality and team player, dependable, aptitude for accuracy, detail and organization skills. PC and/or encoder experience.
• Must be detail-oriented.
• Will need to work independently with minimal direct supervision and be able to resolve problems independently.
• Must have both strong critical thinking and time management skills.

Work Experience:

• Minimum five years of experience as clinical nurse, inpatient or outpatient coder or two years of experience as a Clinical Documentation Integrity Specialist.
• ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience preferred.

Physical Requirements:

• Ability to communicate and exchange accurate information.
• Ability to perform work in a stationary position for extended periods.
• Ability to work with physical records or operate a computer or other office equipment.
• In some locations, ability to travel throughout the hospital system.
• In some locations ability to move up to 25 lbs.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment as required for procedures.