Clinical Documentation Specialist: Optimize HCC & E/M

University Hospitals; Cleveland (OH); On-site; USD 65,000 - 90,000; Full time

Job summary

University Hospitals is seeking a Clinical Documentation Specialist (CDI) for Pro Fee to serve as a trusted advisor to providers. The role focuses on improving documentation accuracy to reflect patient complexity and appropriate E/M levels, with emphasis on HCC recapture and risk adjustment.

The CDS will perform pre-visit and post-claim reviews, provide education on coding and billing practices, and collaborate with CDI program colleagues to enhance documentation quality and compliance across

Qualifications

• Extensive clinical knowledge and understanding of pathophysiology.
• Strong critical thinking to identify indicators supporting patient acuity.
• Excellent written and verbal communication skills required.

Responsibilities

• Assist providers in identifying documentation opportunities for proper HCC capture.
• Perform pre-visit chart reviews and post-claim reviews focusing on E/M levels and HCCs.
• Coordinate with CDI program leadership and colleagues for education and training.

Skills

Clinical knowledge

Critical thinking

Written & verbal communication

Project management

Interpersonal skills

EPIC experience

Microsoft Office

Education material development

Problem solving

Education

High School Equiv. / GED

Associate's Degree

Tools

EPIC

Microsoft Office

Job description

University Hospitals is seeking a Clinical Documentation Specialist (CDI) for Pro Fee to serve as a trusted advisor to providers. The role focuses on improving documentation accuracy to reflect patient complexity and appropriate E/M levels, with emphasis on HCC recapture and risk adjustment.

The CDS will perform pre-visit and post-claim reviews, provide education on coding and billing practices, and collaborate with CDI program colleagues to enhance documentation quality and compliance across