Clinical Documentation Specialist I

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.                        We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.                                    Job TitleClinical Documentation Specialist I                        LocationCleveland                    FacilityRemote Location                     DepartmentHealth Information Management-Cleveland Clinic Akron General                      Job CodeT99120                     ShiftDays                       Schedule8:00am-5:00pm                       Job Summary                         Job DetailsJoin the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building 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. A caregiver in this role works remotely from 8:00 a.m. – 5:00 p.m. 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. 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.  Minimum qualifications for the ideal future caregiver include:High School Diploma/GED or equivalent Five years of experience as clinical nurse, inpatient or outpatient coderOR two years of experience as a Clinical Documentation Integrity Specialist Proficient in the use of department CDI softwareAbility to utilize the reporting functions as needed to develop materials for meetings and presentationsPreferred 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 Strong Med Surg, ICU or ER backgroundPSI and CDI knowledgeKnowledge of physician documentation in the inpatient or outpatient settingKnowledge of inpatient or outpatient payment methodologiesCertified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS within one year of hirePhysical 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.                       The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will in