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Clinical Documentation Specialist I

Cleveland Clinic

Join Cleveland Clinic as a Clinical Documentation Specialist supporting inpatient and outpatient review activities. In this role, you will work with providers and clinical staff to ensure the medical record accurately reflects patient conditions, treatment, and severity of illness.

Responsibilities include reviewing records for diagnosis and procedure specificity, querying and educating providers, supporting accurate DRG/APC/HCC assignment, maintaining CDI review and query documentation, and helping ensure coding and documentation compliance. The role also involves meeting daily productivity targets and participating in education efforts for physicians and clinical staff.

Requirements & Qualifications

Required

  • High School Diploma/GED or equivalent
  • Five years of experience as a clinical nurse or inpatient/outpatient coder
  • Or two years of experience as a Clinical Documentation Integrity Specialist

Preferred

  • Associate’s degree in a healthcare-related field
  • Current Registered Nurse (RN) license in the state of employment
  • Experience with ICD-10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding
  • Coding background

Additional notes

  • Ability to meet CEU requirements to maintain license/certification
  • Working toward ACDIS certification is expected

Location

Cleveland, Ohio, US

Employment Type

Full-time

Experience Level

Intermediate Level

Salary Range

$63,250 - $96,468

Remote work allowed

No

Posted

1 week ago

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