Job Description

Clinical Documentation Specialist (CDI), Pro Fee - (260008VZ)

Description

A Brief OverviewThe Professional Fee Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels thereby supporting the provider's efforts and their professional fee billing. The CDS primarily assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity. The Professional Fee CDS will focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs), which directly impact the patient risk adjusted profile (RAF score) calculated by the associated risk plans. They will also assist with highlighting opportunities based on the provider's medical decision making to appropriately reflect the level of service provided for patient care.The Professional Fee CDS will be responsible for completing pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices, in adherence to compliance standards set by governing entities such as CMS, AHA, etc.• Pre-visit reviews are intended to identify documentation opportunities for the provider to recapture previously documented HCCs diagnoses, or new suspect conditions not previously captured that are identified by the CDS's comprehensive chart reviews. These efforts assist in establishing accurate risk profiles and related health care costs• Post-claim reviews focus on E/M encounters and highlight opportunities based on a provider's medical decision making and the patient's acuity to support appropriate and accurate E/M level assignments as well as any HCCs identified• The Professional Fee CDS will also coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation based on findings from pre-visit and post-claim reviewsWhat You Will DoCoordination with Professional Fee CDI Program leadership and colleagues. Fosters teamwork and utilizes strong team building measuresPerforms pre-visit chart reviews to assist in highlighting relevant documentation and diagnoses in compliance with governing policies and industry guidelines. Applies a “clinical detective” mindset to identify new HCC diagnosis capture opportunities based on appropriate clinical indicators for the patient. Also performs post-claim reviews focused on appropriate E/M level assignments and any opportunities related to level of service and HCCs.Uses performance and outcome data from third-party support or other sources to identify high priority providersCreates specialty-specific education on relevant topics as identified in data analytics and from clinical encounter reviews and post-claim education chart reviewsDevelops and maintains a systematic education schedule and approach for providers in the hospital and clinic/office setting including but not limited to complete documentation, appropriate diagnosis code selection, E/M level assignments and updates to coding guidelines.Delivers ongoing feedback and education to communicate importance of complete documentation and key concepts during regular clinic or provider meetings or on individual basis, as neededUpholds working knowledge and stays current on latest CMS and industry guidelines, with specific understanding of HCCs and implications for documentationMaintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelinesAdditional ResponsibilitiesShares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission. Demonstrates knowledge of and follows departmental and hospital policies and physician office proceduresSeeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications, as required.Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other personnelServes on department and/or institutional committees as requestedPerforms other duties as assigned.Complies with all policies and standards.For specific duties and responsibilities, refer to documentation provided by the department during orientation.Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Qualifications

EducationHigh School Equivalent / GED (Required)Associate's Degree (Preferred)Work Experience3+ years Coding and/or clinical documentation integrity (Required)Knowledge, Skills, & AbilitiesExtensive clinical knowledge and understanding of pathophysiology (Required proficiency)Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record (Required proficiency)Excellent written and verbal communication skills (Required proficiency)Strong project management skills (Required proficiency)Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization (Required proficiency)Ability to work independently in a time-oriented environment (Required proficiency)Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency)Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency)Ability to build education material that is meaningful for providers and team members (Required proficiency)Strong problem solving and investigative skills (Required proficiency)Licenses and CertificationsCertified Coding Specialist (CCS) (Required) orCertified Professional Coder (CPC) or CRC, or other coding or CDI credential (Required)Registered Nurse (RN), Ohio and/or Multi State Compact License (Preferred) orLicensed Practical Nurse (LPN), Ohio and/or Multi State Compact License (Preferred)Physical DemandsStanding OccasionallyWalking OccasionallySitting ConstantlyLifting Rarely up to 20 lbsCarrying Rarely up to 20 lbsPushing Rarely up to 20 lbsPulling Rarely up to 20 lbsClimbing Rarely up to 20 lbsBalancing RarelyStooping RarelyKneeling RarelyCrouching RarelyCrawling RarelyReaching RarelyHandling OccasionallyGrasping OccasionallyFeeling RarelyTalking ConstantlyHearing ConstantlyRepetitive Motions FrequentlyEye/Hand/Foot Coordination FrequentlyTravel Requirements10%

Primary Location

: United States-Ohio-Cleveland

Work Locations

11100 Euclid Avenue

11100 Euclid Avenue

Cleveland 44106

Job

: Medical Billing / Coding / Records

Organization

: UHHS_Coding

Schedule

: Full-time

Employee Status

: Regular - ShiftDays

Job Type

: Standard

Job Level

: Professional

Travel

: Yes, 10 % of the Time

Remote Work: Yes

Job Posting

: Sep 22, 2026, 7:56:43 PM