Clinical Documentation Specialist I

Cleveland Clinic; Fort Lauderdale (FL); Remote; USD 63,000 - 96,000; Full time

Job summary

Cleveland Clinic is seeking a Clinical Documentation Specialist to educate providers and ensure accurate documentation of patient conditions and procedures. You will review DRG/APC/HCC assignments, maintain CDI records, and support CDS staff in a busy clinical environment.

The role emphasizes education of physicians, ongoing certification pursuit with ACDIS, and adherence to industry documentation standards across inpatient and outpatient settings.

Qualifications

• 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.
• Understanding of risk adjusted payment methodologies, HCC assignment and payment methodology, professional coding and billing, outpatient facility coding and billing, APC assignment and OPPS reimbursement methodology.
• Associate’s Degree in healthcare-related field (preferred).
• Registered Nurse (RN) license in the current state of employment (preferred).
• ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience (preferred).
• Clinical Documentation Specialist experience (preferred).
• Experience in chart review or coding (preferred).
• 5+ years as a floor nurse (preferred).
• ICU or cardiac background (preferred).

Responsibilities

• Review principal diagnosis, secondary diagnoses, and procedures to assign working DRG.
• Query and educate providers to obtain diagnostic specificity and accurate reflection of patient condition.
• Adhere to documentation and coding compliance standards.
• Maintain an accurate record of review and query activity in CDI software.
• Meet daily review, query, and response targets.
• Provide guidance to CDS staff and assist management as workload requires.
• Advance education and pursue ACDIS certification.
• Educate physicians and clinical staff on optimal documentation and coding.

Skills

Clinical documentation

Medical coding

Risk adjustment

ACDIS Certification

Education

High School Diploma or GED

Associate’s Degree in healthcare

RN license

Coding knowledge (ICD10-CM, CPT, HCC, HCPCS)

Tools

CDI software

Job description

A caregiver in this role works remotely from 8:00 a.m. – 4:00 p.m. (flexible start/end times).

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build 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.

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.
• Other duties as assigned.

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.
• Other duties as assigned.

Minimum qualifications for the ideal future caregiver include:

• 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
• Understanding of risk adjusted payment methodologies, HCC assignment and payment methodology, professional coding and billing, outpatient facility coding and billing, APC assignment and OPPS reimbursement methodology

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
• Clinical Documentation Specialist experience
• Experience in chart review or coding
• 5+ years of experience working as a floor nurse
• ICU or cardiac background

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 Annual Salary: $63,250.00

Maximum Annual Salary: $96,467.50

The pay range displayed on this job posting reflects the anticipated range for new hires. 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. The pay range displayed does not include any applicable pay practices (e.g., shift differentials, overtime, etc.). The pay range does not include the value of Cleveland Clinic’s benefits package (e.g., healthcare, dental and vision benefits, retirement savings account contributions, etc.).