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Clinical Documentation Specialist I at Cleveland Clinic - ApplyBlast

Clinical Documentation Specialist I

Cleveland Clinic

4 months ago

3.7 on Glassdoor

Remote

Full Time

Executive

0 applicants

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About this role

As a Clinical Documentation Specialist I at Cleveland Clinic, you will review medical records to ensure accurate documentation of patient conditions and procedures. You will query providers to clarify diagnoses, assign appropriate Diagnosis-Related Groups (DRGs), and educate clinical staff on compliance standards. This role supports both inpatient and outpatient settings by optimizing data translation for coding and billing.

Responsibilities

Determine principal and secondary diagnoses to assign working DRGs
Query providers to obtain diagnostic specificity and admission status
Review medical records for chronic disease processes and treatment plans
Educate physicians and staff on optimal documentation and coding standards
Utilize CDI software tools to ensure completion of assigned reviews

Skills

Qualifications

Five years experience as clinical nurse, inpatient or outpatient coderTwo years experience as Clinical Documentation Integrity SpecialistRegistered Nursing (RN) licenseCertified Clinical Documentation Specialist (CCDS or CCDS-O)Associate's Degree in healthcare-related field

About Cleveland Clinic

clevelandclinic.org

Headquarters

Cleveland, Ohio, United States

Company Size

10001+ employees

Founded

1921

View Profile

Cleveland Clinic is a not‑for‑profit academic medical center founded in 1921 that provides comprehensive clinical and hospital care across a large integrated health system. It is known for world‑class specialty care, multidisciplinary teams, and leadership in medical research, education, and health information. The organization operates hospitals, outpatient centers and digital/telehealth services, and employs roughly 65,000 staff to serve patients regionally and internationally.