Clinical Documentation Specialist

Omega Healthcare Management Services • Boca Raton, FL

1d • Remote

About The Position

The Clinical Documentation Specialist coordinates and maintains the elements and requirements of the Clinical Documentation Improvement Program, including staff and physician education, to ensure the highest quality of documentation in support of compliance and accurate representation of the care provided to the patient. This role ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. The specialist will analyze data, create reports, identify trends, and collaborate with coding professionals to resolve discrepancies. They will also work effectively with the CDI team to accomplish departmental goals and demonstrate continued advancement in professional growth, all while complying with company policies, including HIPAA.

Requirements

• Proven experience with ICD-10-CM/PCS coding, DRG assignment, and query processes.
• Familiarity with CMS Inpatient Prospective Payment System (IPPS), risk adjustment methodologies, and value-based purchasing programs.
• Windows, Excel experience.
• EHR: MedHost, Iodine CDI software.
• RN, BSN, or foreign medical graduate (FMG) with strong clinical background; OR RHIA/RHIT/CCS credentialed HIM professional with significant inpatient coding experience.
• Minimum of 3–5 years in clinical practice preferably CCU/ ICU, inpatient coding, or CDI role.
• Certified Clinical Documentation Specialist (CCDS) – ACDIS OR Certified Documentation Improvement Practitioner (CDIP) – AHIMA OR Certified Coding Specialist (CCS) – AHIMA.
• Bachelor’s degree in healthcare field (e.g., nursing, health information management) OR equivalent combination of education/experience combined required. (One year of education equals one year of experience).
• Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field.

Nice To Haves

• Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred.
• Three to five years’ experience in a Clinical Documentation Improvement Program with previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician) of which a minimum of three years’ experience is in a management or supervisory role.
• Bachelor’s or Master’s degree in Nursing, HIM, or related healthcare field.

Responsibilities

• Coordinates and maintains all elements of the Clinical Documentation Improvement Program to meet organizational goals and objectives.
• Meets CDI program objectives, goals, and balance scorecard metrics.
• Ensures timely, accurate, and complete documentation of clinical information for measuring and reporting physician and hospital outcomes.
• Ensures effective communications with key stakeholders.
• Analyzes data and creates reports to meet desired outcomes.
• Identifies trends and opportunities for improvement in clinical documentation.
• Meets program quality and productivity guidelines and standards.
• Collaborates with coding professionals to fully support the needs of clinical code assignment and resolves identified discrepancies.
• Works effectively with CDI team members to accomplish departmental goals.
• Demonstrates continued advancement in professional growth.
• Performs duties in compliance with Company’s policies and procedures, including those related to HIPAA and compliance.

Benefits

• Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances.

What This Job Offers

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