Remote 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

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.