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Cleveland Clinic



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Health Care-Cleveland Clinic
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Job Title

Clinical Documentation Specialist - HDS Coding Job


Reference Title
HR Use Only: Clinical Documentation Specialist - HDS Coding
Hospital: Cleveland Clinic Main Campus & Family Health Centers
Department: HDS CODING
Job Code: T99120
Pay Grade: 13
Schedule: Full Time
Shift: Days
Hours: 7am-3:30pm
Job Details:

JOB SUMMARY: Ensures accurate hospital case-mix index, severity and risk of mortality profiles, and appropriate DRG assignment through concurrent review of the medical record for all relevant clinical conditions and procedures using knowledge of clinical conditions and documentation requirements, which impacts these metrics through 1:1 provider education.

Job Responsibilities: Concurrent review / Query process: Based on review of the existing medical record, determines principal diagnosis, qualifying secondary diagnoses, impacting procedures and assigns appropriate working DRG. Queries and educates providers to obtain greatest possible diagnostic specificity, and present on admission status, to accurately reflect the patients condition. Adheres to industry standards pertaining to compliance. Optimal use of Clinical Documentation Improvement (CDI) software: Maintains an accurate and complete record of review and query activity in the CDI software system. Utilizes tools available in 3M CDIS to ensure completion of reviews in assigned areas, and optimal selection of working MS DRG and APR DRG. Becomes proficient in the use of new technology as it is deployed. Consistently maintains quality and productivity standards: Meets daily review, query and query response targets. Participates in department performance improvement and employee engagement activities. Assist coworkers and management as workload requires. Professional development: Participates in department sponsored educational opportunities. Meets hospital specific educational requirements. Takes responsibility for own learning through reading professional journals and attending seminars. Meets CEU requirements to maintain license and certifications. Encouraged to advance formal education and work toward ACDIS certification. Participates as needed in providing 1:1 education to physicians, mid-level providers and other ancillary staff. Other duties as assigned.

Education: Associate's degree in healthcare-related field preferred.

Licensure/Certification/Registration: Registered Nurse (RN) in the state of Ohio preferred.

Experience: Minimum 5 years experience as a hospital inpatient nurse or hospital inpatient coder. Two years experience as a Clinical Documentation Improvement Specialist may offset the degree requirement

Category: Managerial/Professional/Physician

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