Clinical Documentation Specialist II CDI

Mount Sinai Medical Center • Miami Beach, FL

1d • 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 specialist conducts timely chart reviews, identifies documentation gaps, and issues clinically sound queries while working toward high response and agreement rates. This position collaborates with providers and interdisciplinary teams, maintains accurate data in 3M 360 and Epic, supports financial and quality review projects, mentors new staff, and assists Rehab services with compliance and tier optimization. The role is remote or hybrid and requires Florida residency.

Requirements

• R.N. or medical graduate.
• Bachelor’s degree; the education section also lists medical school graduate.
• Ability to apply ICD-10 coding guidelines and knowledge of DRGs, CCs, and MCCs.
• Strong clinical reasoning, critical thinking, and communication skills.
• Florida residency is required.

Nice To Haves

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

Responsibilities

• Apply ICD-10 coding guidelines and maintain 85% working DRG accuracy.
• Use knowledge of DRGs, CCs, and MCCs to assess query impact, prioritize work, and focus efforts efficiently.
• Review records for assigned units within 24–48 hours of inpatient admission and again every 2–3 days until discharge as needed; manage approximately 16–20 charts daily.
• Identify documentation improvement opportunities using clinical reasoning, critical thinking, and coding concepts.
• Formulate clinically credible physician queries and achieve 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 they are answered; manage Epic query workqueues and 3M 360 pending-query swim lanes regularly.
• Use 3M 360 Encompass and accurately enter working and baseline DRGs, daily 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 the response 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 in a timely and effective manner.
• Assist the manager with reconciliation of monthly query reports and other financial reports as needed.
• Review individual monthly financial reports to ensure financially impacting queries have the proper baseline DRG and that final and working DRGs match for accurate 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, querying Rehab physicians for supporting diagnoses as needed, and evaluating rehab visits for tier improvement opportunities by querying for 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