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Under minimal direction, fosters accurate and complete clinical documentation in the inpatient and ambulatory EHR through application of clinical documentation improvement (CDI) theory and practice, combined with knowledge of clinical conditions and documentation requirements which support the DRG, APC and HCC assignment, severity of illness, risk of mortality, quality measures, and reimbursement rules.

Responsibilities:

+ Performs review of inpatient or outpatient EHR and query process according to department guidelines.

+ Maintains an accurate record of EHR review and query activity in the CDI software system.

+ Collaborates with CDI leadership to develop and present educational materials for peers as well as clinical team.

+ Represents the department at institute, division or hospital department meetings upon request of CDI leadership.

+ Acts as peer mentor for new CDI staff and as a resource for inpatient or outpatient CDIS I caregivers.

+ Meets or exceeds daily reviews, query and query response targets.

+ Assists co-caregivers as workload requires.

+ Works with department leadership on special projects and performance improvement initiatives.

+ Identifies trends and opportunities for improvement in inpatient or outpatient clinical documentation.

+ Ensures effective communication with physicians and other clinical staff.

+ Conducts second level reviews as part of the process improvement initiatives.

+ Leads department teams and committees as assigned by leadership.

+ Facilitates and participates in caregiver engagement activities.

+ Facilitates and participates in department sponsored educational opportunities.

+ Meets hospital specific educational requirements.

+ Demonstrates continued advancement in professional growth: Takes responsibility for own learning through reading professional journals and attending webinars/seminars.

+ Encouraged to advance formal education and work toward ACDIS certification.

+ Completes required CEUs to maintain professional licensure and certification.

+ Other duties as assigned.

Education:

+ Bachelor's degree in healthcare related field.

Certifications:

+ Registered Nurse (RN) in the state of Ohio preferred.

+ Certified Clinical Documentation Specialist (CCDS or CCDS-O) from ACDIS must be obtained within 1 year of hire.

Work Experience:

+ A minimum of two years of experience as inpatient or outpatient CDIS I required.

+ Offset: High School Diploma/GED or equivalent and CCDS or CCDS-O certification and three years of inpatient or outpatient CDI experience.

+ Proficient in the use of department CDI software and able to utilize the reporting functions as needed to develop materials for meetings and presentations, as requested by CDI leadership.

+ Knowledge of physician documentation in the inpatient or outpatient setting preferred.

+ Knowledge of inpatient or outpatient payment methodologies preferred.

Physical Requirements:

+ Physical demands require standing, walking, sitting, lifting, carrying up to 25 lbs.

+ Close, distant, and color vision is required.

+ The work environment is at a moderate noise level (business office with phones, copiers, computers, printers, and ambulatory nursing units).

+ Ability to work under stress and meet deadlines.

Personal Protective Equipment:

+ Follows standard precautions using personal protective equipment as required for procedures.

Pay Range

Minimum hourly: $33.46

Maximum hourly: $51.03

The pay range displayed on this job posting reflects the anticipated range for new hires. While the pay range is displayed as an hourly rate, Cleveland Clinic recruiters will clarify whether the compensation is hourly or salary. A successful candidate's actual compensation will be determined after taking factors into consideration such as the candidate's work history, experience, skill set, and education. This is not inclusive of the value of Cleveland Clinic's benefits package, which includes among other benefits, healthcare/dental/vision and retirement.

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities