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Clinical Documentation Specialist I
Cleveland Clinic. Provide education to providers and clinicians so medical-record documentation accurately reflects patient conditions and treatments .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Integrity, including accurate coding and compliance with documentation standards. Proficient in utilizing CDI software and educating healthcare providers on documentation practices to ensure precise patient records.
Highest-signal resume keywords
Clinical Documentation IntegrityICD10-CM CodingCPT CodingCertified Clinical Documentation SpecialistCDI Software Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Inpatient CodingOutpatient CodingDRG AssignmentHCC AssignmentDiagnostic SpecificityDocumentation ComplianceClinical Knowledge EvaluationReporting Functions UtilizationChronic Disease ProcessesPayment Methodologies Knowledge
Soft Skills
Education and TrainingCommunication SkillsAttention to DetailTeam CollaborationProblem-Solving
Tools & Technologies
CDI SoftwareElectronic Health Records
Certifications & Qualifications
Certified Clinical Documentation SpecialistRegistered Nurse
Industry Keywords
Medical-Record DocumentationProvider EducationSeverity of IllnessRisk of MortalityClinical Documentation Standards
About the role
Key responsibilities & impact- Provide education to providers and clinicians so medical-record documentation accurately reflects patient conditions and treatments
- Review 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
- Maintain complete records of review and query activity in CDI software
- Use CDI software tools to complete assigned reviews and select working MS DRG and APR DRG
- Meet daily review, query, and query-response targets
- Guide CDS staff regarding processes, procedures, and coverage determinations as workload requires
- 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, ASCs, and Emergency Departments
- Apply clinical knowledge to evaluate documentation, chronic disease processes, medications, diagnostic information, and treatment plans for coding
- 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 clinical nurse, inpatient or outpatient coder OR two years of experience as a Clinical Documentation Integrity Specialist
- Proficient in the use of department CDI software
- Ability to utilize reporting functions to develop materials for meetings and presentations
- Associate’s Degree in 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
- Strong Med Surg, ICU or ER background preferred
- PSI and CDI knowledge preferred
- Knowledge of physician documentation in inpatient or outpatient settings preferred
- Knowledge of inpatient or outpatient payment methodologies preferred
- Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS within one year of hire preferred
- Ability to meet CEU requirements to maintain license and certification
- Physical 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
- Ability to comply with controlled-substance testing and annual influenza vaccination program or approved exemption
Benefits
Comp & perks- Remote work from 8:00 a.m. – 5:00 p.m.
- Equal opportunity employment
- Drug-free work environment
- Annual influenza vaccination program or approved exemption
- Personal protective equipment (PPE) as required