CLINICAL DOCUMENTATION SPECIALIST II

CO1000 H. Lee Moffitt Cancer Center and Research Institute Hospital, Inc.; United States; On-site; USD 83,000 - 126,000; Full time

Job summary

Moffitt Cancer Center in Florida is seeking a Clinical Documentation Specialist II to improve the quality and completeness of provider-based documentation in the medical record. You will work directly with treating providers to reflect the severity of illness, risk of mortality, and complexity of care.

The role requires four years of acute care clinical documentation experience, knowledge of ICD-10-CM/PCS, and relevant certifications such as CCDS/CDIP/CDEI or an active RN license.

Qualifications

• Associate degree in Nursing/HIM or related field
• Four years of acute care clinical documentation experience
• Knowledge of ICD-10-CM, ICD-10-PCS coding
• Ability to perform independent queries and research methods

Responsibilities

• Improve documentation quality and completeness in provider records
• Assist providers to reflect illness severity, risk of mortality, and complexity of care
• Collaborate with physicians, mid‑levels, and nursing staff to educate on documentation
• Apply evolving AHIMA/ACDIS standards and coding updates
• Use MS Office, Cerner EHR, and Optum 360 eCAC to support documentation management

Skills

Clinical knowledge

Coding skills

Interpersonal skills

Writing skills

Education

Associate’s Degree in Nursing, HIM or Healthcare

RN license

CCDS (Certified Clinical Documentation Specialist)

CDIP (Certified Documentation Integrity Practitioner)

CDEI (Certified Documentation Expert Inpatient)

Tools

MS Office

Cerner EHR

Optum 360 eCAC

Job description

Working at Moffitt is both a career and a mission: to contribute to the prevention and cure of cancer. As the only National Cancer Institute-designated Comprehensive Cancer Center based in Florida, Moffitt employs some of the best and brightest minds from around the world. Join a dedicated team of nearly 11,000 who are shaping the future we envision. Moffitt has been recognized as a Best and Brightest Company to Work For in the Nation and is continually named one of the Tampa Bay Times’ Top Workplaces.

The Clinical Documentation Specialist II is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers.

This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchical condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with providers.

The Clinical Documentation Specialist II assesses clinical documentation through extensive medical record review and utilization of clinical judgment, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. This position conducts independent research to ensure compliance when developing provider queries, while interpreting and applying evolving standards from governing bodies AHIMA and ACDIS and maintaining up-to-date knowledge of coding changes and updates released each April and October.

Extensive collaboration with physicians, mid-levels, nursing staff, other patient care givers to include developing and delivering education, which will be accomplished with zoom meetings, telephonic discussions, and email.

Preferred Experience 2 years of experience in oncology Vizient experience

Salary Range $82,934.80-$126,427.60 Salary ranges posted for this position represent the expected base pay range for the role. Actual compensation may vary based on location and a variety of job-related factors, including experience, skills, education, and internal equity among Team Members in similar positions. We are committed to maintaining fair and equitable pay practices and regularly review compensation to ensure alignment across our workforce.

Credentials and Experience

• Associate’s Degree – field of study: Nursing, HIM or another Healthcare related field
• A minimum of four (4) years' acute care clinical documentation experience to include:
  • Applying Medicare, Medicaid and Commercial payer regulations, charging and coding guidelines
  • Healthcare regulations
  • ICD-10-CM, ICD-10-PCS coding
  • Performing independent queries

Certifications

• (CCDS) Certified Clinical Documentation Specialists from ACDIS
• (CDIP) Certified Documentation Integrity Practitioner from AHIMA
• (CDEI) Certified Documentation Expert Inpatient from AAPC
• Registered Nurse (RN) *in lieu of a certification listed above, an (active) RN will satisfy the certification requirement

Minimum Skills/Specialized Training Required

• Proven record of combining clinical knowledge and coding skills
• Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers to address the opportunities in documentation.
• Proficient in computer skills including MS Office, Optum 360 eCAC, Cerner EHR
• Organized, analytical, superior interpersonal and writing skills
• Dependable, self-directed with critical thinking, problem solving, and deductive reasoning
• Knowledge of healthcare regulatory environment
• Understand and support clinical documentation management strategies
• Must be flexible to accommodate clinician schedules
• Knowledge of Case Mix Index and how it is influenced

Equal Employment Opportunity Moffitt Cancer Center is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, or protected veteran or disabled status. We seek candidates whose skills, and personal and professional experience, have prepared them to contribute to our commitment to diversity and excellence.

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