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Clinical Documentation Specialist
Cleveland Clinic. Provide education to providers and clinicians to ensure clinical conditions and procedures are accurately documented in medical records .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Integrity, including accurate documentation, coding compliance, and effective communication with healthcare providers. Proficient in utilizing CDI software tools and adhering to coding standards to optimize DRG assignments and ensure quality patient care.
Highest-signal resume keywords
Clinical Documentation IntegrityICD10-CM CodingHCC CodingCDI Software ProficiencyRegistered Nurse (RN)
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Inpatient CodingOutpatient CodingDRG AssignmentQuerying ProvidersClinical Documentation ReviewDisease-Process IdentificationDocumentation ComplianceMedical Record ReviewSurgical CodingICU Experience
Soft Skills
Effective CommunicationEducation and TrainingAttention to DetailProblem-SolvingTeam Collaboration
Tools & Technologies
EPIC3MCDI SoftwareMicrosoft Office
Certifications & Qualifications
ACDIS CertificationRegistered Nurse (RN)
Industry Keywords
Clinical DocumentationHealthcare ComplianceMedical CodingSeverity of IllnessRisk of MortalityAmbulatory Surgery CentersEmergency DepartmentsDocumentation StandardsCoding ComplianceProvider Education
About the role
Key responsibilities & impact- Provide education to providers and clinicians to ensure clinical conditions and procedures are accurately documented in medical records
- Review documentation for correct DRG, APC, and HCC assignment, severity of illness, and risk of mortality
- Determine principal diagnosis, qualifying secondary diagnoses, impacting procedures, and appropriate working DRG for inpatient cases
- Query and educate providers to obtain diagnostic specificity and present-on-admission status
- Adhere to documentation and coding compliance standards
- Record review and query activity accurately in CDI software
- Use CDI software tools to complete reviews and optimize working MS DRG and APR DRG selection
- Meet daily review, query, and query-response targets
- Provide guidance to CDS staff regarding processes, procedures, and coverage determinations
- Participate in education for physicians, advanced practice providers, and clinical ancillary staff
- Conduct outpatient medical-record reviews across provider offices, physician- and hospital-owned clinics, Ambulatory Surgery Centers, and Emergency Departments
- Clarify clinical documentation by querying providers and medical team members
- Apply clinical knowledge to evaluate how records translate into coded data, including diagnoses, medications, diagnostics, and treatment plans
- Educate providers on documentation and disease-process identification to support accurate coding and billing
Requirements
What you’ll need- High School Diploma/GED or equivalent
- Five years of experience as a clinical nurse, inpatient or outpatient coder, OR two years of experience as a Clinical Documentation Integrity Specialist
- Associate’s Degree in a healthcare-related field preferred
- Registered Nurse (RN) in the current state of employment preferred
- ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience preferred
- ICU experience preferred
- Surgical and strong CDI experience preferred
- Experience with EPIC, 3M, and Microsoft preferred
- Ability to meet CEU requirements to maintain license and certification
- Ability to obtain ACDIS certification
- Ability to work remotely from 8:00 a.m. to 4:00 p.m.
- Ability to stand, walk, sit, lift, and carry up to 25 lbs.
- Close, distant, and color vision
- Manual dexterity to handle records and operate a PC
- Compliance with standard precautions and required personal protective equipment
- Successful controlled-substance testing after an offer of employment
- Compliance with the annual influenza prevention program or an approved exemption
Benefits
Comp & perks- Annual influenza vaccination or approved exemption under Cleveland Clinic Health System’s influenza prevention program
- Equal opportunity employment in a drug-free environment
- Support and appreciation from Cleveland Clinic Health System
- Career development and formal education advancement opportunities
- CEU support to maintain license and certification