CLINICAL DOCUMENTATION SPECIALIST Sr

Moffitt Cancer Center

83d • $80,974 - $123,365

About The Position

The Clinical Documentation Specialist Senior improves the quality and completeness of provider-based clinical documentation in medical records by working directly with providers. The role helps ensure documentation accurately reflects each patient's severity of illness, risk of mortality, complexity of care, and hierarchical condition categories. The Senior identifies documentation improvement opportunities, conducts collaborative discussions with providers, and serves as a subject matter expert who supports less experienced team members, trains and onboards new hires, and participates in special projects assigned by Mid Revenue Cycle leadership.

The position assesses documentation through extensive medical record review, clinical judgment, use of artificial intelligence, and collaboration with providers to clarify and accurately represent patients' medical conditions. It conducts independent research to ensure provider queries comply with applicable standards, applies evolving AHIMA and ACDIS guidance, and stays current with coding updates released each April and October.

The role collaborates with physicians, mid-level providers, nursing staff, other caregivers, HIM coding staff, and educators. Education and communication may take place through onsite meetings, Zoom, telephone discussions, rounding, and email. The work supports appropriate reimbursement for services rendered and complete, accurate clinical information for profiling and outcomes reporting.

Requirements

• Associate degree in nursing, health information management (HIM), or another healthcare-related field.
• At least six years of acute-care clinical documentation experience.
• Experience applying Medicare, Medicaid, and commercial payer regulations, charging and coding guidelines, and healthcare regulations.
• Experience with ICD-10-CM and ICD-10-PCS coding.
• Experience performing independent queries.
• Hold one of the following certifications: CCDS from ACDIS, CDIP from AHIMA, or CDEI from AAPC; an active RN license satisfies the certification requirement in lieu of a listed certification.
• Demonstrated ability to combine clinical knowledge and coding skills.
• Ability to recognize documentation improvement opportunities and collaborate with providers to address them.
• Computer proficiency, including MS Office, Optum 360 eCAC, and Cerner EHR.
• Organized and analytical, with superior interpersonal and writing skills.
• Dependable and self-directed, with critical thinking, problem-solving, and deductive reasoning skills.
• Knowledge of the healthcare regulatory environment and clinical documentation management strategies.
• Flexibility to accommodate clinician schedules.
• Knowledge of Case Mix Index and how it is influenced.

Nice To Haves

• Four years of oncology experience.
• Vizient experience.

Responsibilities

• Review medical records for documentation quality, completeness, and accuracy, ensuring coded diagnoses reflect the level of care and patient status, including severity of illness and risk of mortality.
• Identify documentation gaps, conflicting diagnoses, and unspecified diagnoses, and clarify them with providers to support accurate ICD-10-CM/PCS coding.
• Meet and maintain established quality and productivity measures.
• Provide ongoing education to providers through onsite meetings, Zoom, telephone discussions, rounding, and email; supply educational materials and tools to individual practitioners and clinician groups.
• Identify and share opportunities to improve documentation of patients' severity of illness, risk of mortality, comorbid conditions, and other condition categories.
• Develop clear, concise, compliant written and verbal provider queries to clarify unclear, incomplete, or unspecified documentation.
• Use software systems and a Natural Language Processor (NLP) to review and compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and on time.
• Report key performance indicators and other significant metrics to the Medical Executive Committee through presentations to the Medical Records Committee and to other committees as directed.
• Serve as a subject matter expert and assist less experienced team members in following operational policies.
• Train and onboard new team members and participate in special projects assigned by Mid Revenue Cycle leadership.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree