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Clinical Documentation Specialist I

About the Employer | www.clevelandclinic.org
Annual Salary

Job Description

Under minimal direction, will provide concurrent and retrospective review of the medical record, 1:1 provider education, and educate clinicians to ensure the documentation of all clinical conditions and procedures within the medical record accurately reflect the condition(s) and treatment(s) of the patient. In addition, ensures that documentation reflects the appropriate DRG assignment or APC and HCC assignment, severity of illness, risk of mortality, and quality measures. Coordinates provider educations, and adheres to industry standards pertaining to compliance. This is a local remote position for Ohio residents.

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.

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:

  • 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.

Location

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    They do business with integrity and rational thinking. Overall, it's an excellent place to work, with products that are winning in the marketplace.