Clinical Documentation Specialist I – Neuro Expansion

Job Description: • Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. • 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. • Review for correct DRG, APC and HCC assignment, severity of illness and risk of mortality to align with industry standards regarding compliance. • 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. • 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. Requirements: • 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 • 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) • ICU or Med/Surg experience (preferred) • EPIC, 3M and Microsoft Office skills (preferred) Benefits: • We know that fully supporting our caregivers is what creates the best outcomes for our patients. Our outstanding, comprehensive offerings are an investment in your health, well-being and future.