Clinical Documentation Specialist Ii

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.
We all have the power to help, heal and change lives - beginning with our own. That's the power of the Cleveland Clinic Health System team, and The Power of Every One.
Job Title
Clinical Documentation Specialist II
Location
Weston
Facility
CC Florida Hospital Weston
Department
Documentation Review-Cleveland Clinic Florida
Job Code
000979
Shift
Days
Schedule
8:00am-4:30pm
Job Summary
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 has contributed to earning the No. 1 hospital ranking in the Miami-Fort Lauderdale metro area and remains a top hospital in Florida, according to the U.S. News & World Report.
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.
Job Details
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.

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after 90 days.
Cleveland Clinic Health System administers an influenza prevention program as well as a COVID-19 vaccine program. You will be required to comply with both programs, which will include obtaining an influenza vaccination on an annual basis, and being fully vaccinated against COVID-19, or obtaining an approved exemption.
Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.
Please review the Equal Employment Opportunity poster.
Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities