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RN-Clinical Documentation Integrity Specialist I - Cleveland, United States - Cleveland Clinic
Description
Join Cleveland Clinic Weston Hospital's team of caregivers that remain on the leading edge of technology and education all while consistently providing patient-centered healthcare.
As part of Cleveland Clinic's Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale metro area and Florida.
Here, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.
As a Clinical Documentation Integrity Specialist, you will:
Provide concurrent and retrospective review of the medical record, 1:1 provider education, and educate clinicians to ensure the documentation of all clinical conditions and procedures within the medical record accurately reflect the condition(s) and treatment(s) of the patient.
Ensure that documentation reflects the appropriate DRG assignment or APC and HCC assignment, severity of illness, risk of mortality, and quality measures.
Coordinate provider education. Adhere to industry standards pertaining to compliance.The ideal future caregiver is someone who:
Has at least five years of nursing floor experience in either a Medical/Surgical, Telemetry or Intensive Care Unit. Thrives working both independently and as part of a team. Demonstrates a strong work ethic. Has excellent communication, critical thinking and time management skills.
This opportunity allows you to work remotely while also gaining the skills and experience to advance your career into CDS II, Quality Educator, public speaking and leadership positions.
At Cleveland Clinic, we know what matters most.That's why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you.
Here, you'll find that we offer:
resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future.
When you join Cleveland Clinic, you'll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.
Responsibilities:
Inpatient Clinical Documentation Specialist:
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 patient's condition.
Adheres to industry standards pertaining to documentation and coding 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 CDI software 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 co-caregivers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations.
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 certification. Encouraged to advance formal education and work toward obtaining ACDIS certification. Participates as needed in providing 1:1 educations to physicians, advanced practice providers and other clinical ancillary staff.
Other duties and assigned.
Outpatient Clinical Documentation Specialist:
Concurrent review/query process:
Conduct reviews of medical records for patients in a variety of outpatient settings including but not limited to provider offices, physician and hospital"owned clinics, ambulatory surgery centers, and hospital emergency departments.
Queries providers and medical team members caring for the patient to clarify clinical documentation.Apply their clinical knowledge to evaluate how the medical record will translate into coded data, including reviewing provider and other clinical documentation, chronic disease processes, medications and their indications, diagnostic information, and treatment plans.
Educate providers about optimal documentation and identification of disease processes to ensure proper reflection of severity of illness, complexity, and acuity, and facilitate accurate coding and billing.
Understand risk adjusted payment methodologies, HCC assignment and payment methodology,professional coding and billing, outpatient facility coding and billing, APC assignment, and OPPS reimbursement methodology and share this knowledge with providers and members of the clinical team.
Optimal use of clinical documentation improvement software:
Maintains an accurate and complete record of review and query activity within the CDI software system. Utilizes tools available in CDI software system to ensure completion of reviews. 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.
Assists co-workers and management as workload requires by providing guidance to clinical documentation improvement staff regarding efficient processes/procedures and coverage determinations.
Professional development:
Participates in department sponsored educational opportunities. Meets hospital specific educational requirements. Takes responsibility for own learning through reading professional journals and attending webinars/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 clinical team (physicians, advanced practice providers, and ancillary staff).Other duties as assigned.
Education:
High School Diploma/GED or equivalent required.
Associate's degree in healthcare related field preferred.
Certifications:
Registered Nurse (RN) in the current state of employment plexity of Work:All employees are expected to meet the standards of performance outlined in the Organizational-Wide Competencies listed below as applied to the position:
World Class Service Orientation:
Includes attitude, behavior, interpersonal skill, and problem solving that enable an employee to respond to internal and external customer needs and expectations in a positive manner
Adaptability:
Includes teamwork and flexibility needed to fulfill job responsibilities including adapting to changes in work environment and accepting supervisory feedback
Efficiency and Effectiveness:
Includes quantity and quality of desired work, as well as organization skills necessary to perform successfully
Essential Job Requirements:
Includes adherence to all relevant policies, procedures, and guidelines affecting the work environment, including maintenance of required competencies and communication skills.
Supervisory Responsibilities (if applicable): Includes overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraintsNote:
The above stated duties are intended to outline those functions typically performed by individuals assigned to this classification.
This description of duties is not intended to be all inclusive nor to limit the discretionary authority of supervisors to assign other tasks of similar nature or level of responsibility.
Thorough and up-to-date clinical skills.Excellent written and verbal communication skills required.
Ability to write inquiries to physicians.
Ability to effectively communicate with physicians to relay and obtain information as well as respond to questions.
Assertive personality and team player, dependable, aptitude for accuracy, detail and organization skills. PC and/or encoder experience.
Must be detail-oriented.
Will need to work independently with minimal direct supervision and be able to resolve problems independently.
Must have both strong critical thinking and time management skills.
Work Experience:
Minimum five years of experience as clinical nurse, inpatient or outpatient coder or two years of experience as a Clinical Documentation Integrity Specialist.
Physical Requirements:
Physical demands require standing, walking, sitting, lifting, one-third (or more) of the time.
This position requires carrying or wheeling 10-25 pounds.
PC/CRT skills are required one-fourth of the time.
Close vision is required, typical physical demands require reading handwritten notes on busy inpatient nursing units.
Requires manual dexterity to grasp and handle records and to operate a PC computer in the course of work.
The work environment is at a moderate noise level (hospital/nursing unit). Ability to work under stress and meet deadlines.
Personal Protective Equipment:
Follows Standard Precautions using personal protective equipment as required for procedures
Pay RangeMinimum hourly:
$30.41Maximum hourly:
$46.38The 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.
