Clinical Documentation Specialist Senior

About This Role

This senior-level role focuses on improving the quality and completeness of clinical documentation within medical records by working directly with healthcare providers. The specialist acts as a subject matter expert, assisting less experienced team members and leading training for new hires. The position involves reviewing medical records, utilizing clinical judgment and artificial intelligence, and collaborating with providers to accurately reflect patient care and conditions.

Responsibilities

• Review medical records for quality, completeness, and accuracy of documentation, ensuring coded diagnoses reflect the level of patient care, severity of illness, and risk of mortality
• Identify documentation gaps, conflicting, or unspecified diagnoses and clarify them with providers to assign the most accurate ICD-10-CM/PCS code
• Meet and maintain established quality and productivity measures per policies
• Deliver ongoing education to providers through on-site meetings, Zoom meetings, telephonic discussions, rounding, and email
• Provide supplemental educational material and tools related to documentation improvement practices for individual practitioners and groups of clinicians
• Identify and share documentation improvement opportunities with providers to capture accurate severity of illness, risk of mortality, comorbid conditions, and all other condition categories
• Develop clear, concise, and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or unspecified documentation
• Utilize software systems and Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely
• Report Key Performance Indicators and other significant metrics regularly to the Medical Executive Committee via presentation to the Medical Records Committee and other directed committees
• Function as a subject matter expert on the team, assisting less experienced team members in following operational policies
• Train and onboard new team members
• Participate in special projects assigned by the Mid Revenue Cycle leadership

Requirements

• Associate’s Degree in Nursing, HIM, or another Healthcare-related field
• A minimum of six years' acute care clinical documentation experience, including:
• Applying Medicare, Medicaid, and Commercial payer regulations, charging, and coding guidelines
• Healthcare regulations
• ICD-10-CM, ICD-10-PCS coding
• Performing independent queries
• Proven record of combining clinical knowledge and coding skills
• Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers
• 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 abilities
• Knowledge of the 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:

• Four years' experience in oncology
• Vizient experience

Certifications

• (CCDS) Certified Clinical Documentation Specialists from ACDIS
• (CDIP) Certified Documentation Integrity Practitioner from AHIMA
• (CDEI) Certified Documentation Expert Inpatient from AAPC
• Registered Nurse (RN) (an active RN license will satisfy the certification requirement in lieu of a listed certification)

About the Company

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