Clinical Documentation Specialist II CDI

Mount Sinai Medical Center of Florida • Miami Beach, FL

7d • Hybrid

About The Position

The Clinical Documentation Specialist II improves the accuracy and quality of inpatient medical record documentation to support correct DRG assignment, coding integrity, and optimized reimbursement. The position conducts timely chart reviews, identifies documentation gaps, and issues clinically sound queries while working to maintain high query response and agreement rates. The specialist collaborates with providers and interdisciplinary teams, maintains accurate information in 3M 360 and Epic, supports financial and quality review projects, mentors new staff, and assists Rehab services with compliance and tier optimization. This position is remote or hybrid and requires Florida residency.

Requirements

• R.N. or medical graduate.
• Medical school graduate; a bachelor’s degree is also listed under degree requirements.
• Experience in critical care or intensive care patient care is preferred.
• Medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience is desired.

Nice To Haves

• R.N. certification preferred.
• Critical care or intensive care patient care experience preferred.
• Medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired.

Responsibilities

• Apply ICD-10 coding guidelines and maintain 85% Working DRG accuracy.
• Review patient records in assigned units within 24–48 hours of inpatient admission and subsequently every 2–3 days until discharge, as needed; manage approximately 16–20 charts daily.
• Use clinical reasoning, critical thinking, and coding concepts to identify documentation improvement opportunities and prioritize queries based on their likely impact.
• Formulate clinically credible physician queries and achieve query response and agreement rates above 85%.
• Maintain effective working relationships with physicians, residents, physician assistants, nurse practitioners, nurses, case managers, and other healthcare providers.
• Maintain a query rate of 25–35% of all patient records reviewed.
• Follow up daily on pending queries until answered, and regularly manage Epic query workqueues and 3M 360 pending-query swim lanes.
• Use 3M 360 Encompass and accurately enter patients’ working and baseline DRGs, review notes, and other required information.
• Conduct retrospective reviews for assigned quality and revenue projects.
• Document query narratives, expected and actual responses, and the date and location of responses in the medical record.
• Mentor and train new employees in conjunction with the department Manager.
• Periodically review the mismatch report, ensure working DRGs are optimal, and address discrepancies with HIM coding staff promptly and effectively.
• Support the manager with reconciliation of monthly query reports and other financial reports as needed.
• Review individual monthly financial reports to ensure accounts with financially impactful queries have the proper baseline DRG and that final and working DRGs match for optimal reporting.
• Report unanswered queries that would otherwise have affected DRG weight for tracking.
• Support the Rehab team by reviewing potential rehab admissions for CMS compliance criteria and querying Rehab physicians as needed to include supporting diagnoses.
• Evaluate Rehab visits for potential tier improvements by querying physicians for potentially qualifying diagnoses.

Benefits

• Health benefits
• Life insurance
• Long-term disability coverage
• Healthcare spending accounts
• Retirement plan
• Paid time off
• Pet insurance
• Tuition reimbursement
• Employee assistance program
• Wellness program
• On-site housing for select positions

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level