Clinical Documentation Specialist II

About This Role

This specialist role focuses on improving the quality and completeness of clinical documentation in medical records by working directly with providers. The position assists treating providers in accurately reflecting the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories. This involves recognizing opportunities for documentation improvement and engaging in collaborative discussions with providers.

Responsibilities

• Assess clinical documentation through extensive medical record review and utilization of clinical judgment
• Deploy artificial intelligence
• Collaborate directly with providers to clarify documentation to accurately and completely reflect patients' medical conditions
• Conduct independent research to ensure compliance when developing provider queries
• Interpret and apply evolving standards from governing bodies AHIMA and ACDIS
• Maintain up-to-date knowledge of coding changes and updates released each April and October
• Collaborate extensively with physicians, mid-levels, nursing staff, and other patient caregivers
• Develop and deliver education through Zoom meetings, telephonic discussions, and email

Requirements

• Proven record of combining clinical knowledge and coding skills
• Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers to address documentation opportunities
• Proficient in computer skills including MS Office, Optum 360 eCAC, Cerner EHR
• Organized, analytical, with superior interpersonal and writing skills
• Dependable, self-directed with critical thinking, problem-solving, and deductive reasoning
• Knowledge of healthcare regulatory environment
• Understand and support clinical documentation management strategies
• Must be flexible to accommodate clinician schedules
• Knowledge of Case Mix Index and how it is influenced

Nice to have:

• 2 years of experience in oncology
• Vizient experience

About the Company

Moffitt is the only National Cancer Institute-designated Comprehensive Cancer Center based in Florida. It employs nearly 11,000 individuals dedicated to cancer prevention and cure. Moffitt has been recognized as a Best and Brightest Company to Work For in the Nation and is continually named one of the Tampa Bay Times’ Top Workplaces.