Clinical Documentation Specialist

Omega Healthcare Management Services; Boca Raton, Northern (FL, KY); Hybrid; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health benefits

401(k) plan with match

Paid time off

Holiday pay

Professional development

Job summary

Omega Healthcare Management Services seeks a Clinical Documentation Improvement (CDI) Specialist to perform concurrent reviews, ensure accurate chart documentation, and support DRG assignment and hospital reimbursement.

The role requires clinical background in nursing or health information management, with 1–3 years of related experience and strong communication with physicians and coding staff. Relevant CDI tools and a collaborative, quality-driven environment are emphasized.

Qualifications

• Bachelor’s degree in healthcare field (e.g., nursing, health information management) or equivalent combination of education/experience.
• Minimum 1–3 years in clinical quality, utilization management, case management, nursing, coding, or related field.
• Preferred 3–5 years in a Clinical Documentation Improvement Program with supervisory experience.
• Bachelor’s degree with healthcare-related credential.

Responsibilities

• Perform concurrent reviews of medical records to ensure complete and accurate clinical documentation supporting severity of illness and risk of mortality for outcomes reporting and hospital reimbursement.
• Communicate effectively with physicians and clinicians to promote accurate documentation.
• Collaborate with coding staff to improve knowledge and understanding of coding guidelines.
• Meet minimum productivity and quality standards set by the CDI department.

Skills

CDI

ICU CDI

Communication

Written Queries

Excel

PowerPoint

Word

3M CDI

Education

Bachelor's degree in healthcare

Healthcare credential

Tools

Access database management

Job description

Meet CDI program objectives, goals, and balance scorecard metrics.

Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

Ensure effective communications with key stakeholders.

Analyzes data, 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, communicates proficiently with coding professionals to resolve identified discrepancies.

Work effectively with CDI team members to accomplish departmental goals.

Demonstrates continued advancement in professional growth.

• Ability to prioritize and multi-task in a multifaceted environment.
• Demonstrate strong organizational skills and be detail oriented.
• Demonstrate ability to self-motivate, set goals, and meet deadlines.
• Demonstrate excellent presentation, verbal, and written communication skills.

Ability to develop and maintain relationships with key business partners by building personal credibility and trust.

Maintains courteous and professional working relationships with employees at all levels of the organization.

Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required

Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

• Experience: 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 Experience: Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field.
• Preferred Experience: 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.
• Education: Bachelor’s degree, with a healthcare related credential

Additional Eligibility Qualifications

None required

Security Access Requirements

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in "Standard Field Employee” profile.

ADP: Standard Employee Level Access

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcarealso prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at [e-mail]

Required Experience:
5 Years of Beside Clinical Nursing experience in Adult Intensive Care Unit, Critical Care Unit, or Medical Surgery Unit.
Active RN license
Resume must reflect all required experience.
Preferred Experience

2 Years of experience writing providers queries.

2 Years of concurrent experience in Clinical Documentation Integrity working with Concurrent Chart Review.
2 Years of Epic Experience.
Experience with Nuance CDE a plus.

The Clinical Documentation Specialist (CDS) is responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records. The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care. CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM).

Operational

Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.

Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.

Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.

Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.

Efficiently and effectively utilizes UnityPoint Health’s selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes).

Meets the minimum productivity and quality assurance standards established by the CDI department.

Relationship Building/Collaboration

Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.

Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.

Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction.

Collaborates with other hospital departments as needed and directed by CDI leaders.

Required Skills

• CDI
• CDI - Setting - ICU
• CDI - Skill - Communication Skills
• CDI - Skill - Written Query Skills
• System - Microsoft - Excel
• System - Microsoft - PowerPoint
• System - Microsoft - Word
• Systems - 3M CDI

About Us

Founded in 2003, Omega Healthcare Management Services® (Omega Healthcare) empowers healthcare to thrive via intelligent solutions that optimize revenue cycle operations, administrative workflows, care coordination, and clinical research on a global scale. The company works with providers, payers, life science companies, medical device manufacturers, health technology firms, researchers, and industry partners to amplify teams with robust technology, specialty expertise, and operational support. Omega Healthcare serves more than 350 healthcare organizations with 35,000 skilled workers in the United States, India, Colombia, and the Philippines. For more information, visit www.omegahms.com

We offer a comprehensive benefits package that may include health, dental, and vision coverage, voluntary insurance options, a 401(k) plan with employer match, professional development opportunities, paid time off, and holiday pay. Eligible employees may also have the opportunity to participate in bonus programs, commissions, or other variable incentive plans. Benefits and incentive eligibility may vary based on position, location, and tenure.

AAP/EEO Statement

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcarealso prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at [e-mail] .