Clinical Documentation Specialist I

Cleveland Clinic

Cleveland, OH

Job posting number: #7089818 (Ref:19099348000)

Posted: November 30, 2021

Application Deadline: Open Until Filled

Job Description

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.

For this Clinical Documentation Improvement Specialist  position the ideal candidate will have strong Med-Surg experience either as an RN or with Med-Surg CDI or coding.

The position is 100% remote, however only residents of Northeast Ohio will be considered.


  • 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.
  • Other duties as assigned.


  • Associate's degree in healthcare-related field preferred.


  • Registered Nurse (RN) in the current state preferred.

Work Experience:

  • Minimum five 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.

Physical Requirements:

  • Physical demands require standing, walking, sitting, lifting, carrying up to 25 pounds.
  • Close, distant, and color vision is required.
  • 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 (business office with phones, copiers, computers, and printers).

Personal Protective Equipment:

  • Follows standard precautions using personal protective equipment as required. 

Keywords: CDI, Med Surg RN, Med Surg experience, RN, Inpatient RN, Clinical Documentation Improvement Specialist, inpatient coder, Main Campus.


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.

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

By embracing and understanding the diversity EVERY ONE brings, Cleveland Clinic has created an inclusive culture that promotes innovation, growth, and new ideas. This has enhanced our ability to attract the best global talent to provide the best patient experience possible. Cleveland Clinic is pleased to be an equal employment/affirmative action employer: Women/Minorities/Veterans/Individuals with Disabilities. Smoke/drug free environment.

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More Info

Job posting number:#7089818 (Ref:19099348000)
Application Deadline:Open Until Filled
Employer Location:Cleveland Clinic
United States
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