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Cleveland Clinic



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Health Care-Cleveland Clinic
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Job Title

Clinical Documentation Specialist - Hillcrest Hospital Job


Reference Title
HR Use Only: Clinical Documentation Specialist - Hillcrest Hospital
Hospital: Cleveland Clinic Main Campus & Family Health Centers
Department: CDI ADMIN
Job Code: T2435E
Pay Grade: 12
Schedule: Full Time
Shift: Days
Hours: 8am-5pm
Job Details:

This position is located at Hillcrest Hospital

Summary: Ensures hospital case-mix index and severity profiles are accurate by performing Clinic Documentation program activities. Works collaboratively with Medical, Nursing, Case Management, Coding and ancillary staffs to improve the quality of chart documentation and accurately reflect a patients severity of illness and risk mortality.

Job Responsibilities: Works collaboratively with Medical, Nursing, Case Management, and ancillary staffs to improve the quality of chart documentation and to accurately reflect a patients severity of illness. Provides physician education and assistance when needed. Follows coding, HCFA, hospital, and compliance guidelines at all times. Attends and participates in TDI staff meetings and educational sessions. Promotes good morale and cooperation. Meets the operational standards of the Clinical Documentation Program by: Completing accurate reports by established deadline. Other duties as assigned.

Education: Graduate of accredited nursing program or Associates degree in health related field.

Experience: L.P.N. must have five years experience with one year of review experience or coding experience preferred or RHIA/RHIT/CCS with utilization review or concurrent DRG assignment experience. Experience in working directly with physicians is also required. Utilization Review, Case Management, and/or coding and DRG assignment experience strongly preferred.

Licensure/Certification/Registration: Registered Nurse (RN) in the state or Licensed Practical Nurse (LPN).

Physical Requirements: Physical demands include standing and walking one-third of the time. PC/CRT skills are required one-fourth of the time, Close vision is required. This position requires using hand to finger, handle or feel and reaching with hands and arms to retrieve charts one-fourth of the time. Job location is in a moderate noise level environment (hospital/nursing unit). Typical physical demands involve walking, standing, reading physicians handwriting and CRT screen and wheeling job references and dexterity to operate a computer keyboard. Ability to work under stress and meet deadlines. Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Category: Managerial/Professional/Physician

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