CLINICAL DOCUMENTATION SPECIALIST Sr

Moffitt Cancer Center; Florida; On-site; USD 81,000 - 123,000; Full time

Job summary

Moffitt Cancer Center is seeking a Clinical Documentation Specialist Senior to improve provider documentation quality and accuracy in the medical record. You will work with physicians and clinical staff to ensure documentation reflects illness severity, mortality risk, and care complexity, acting as a subject matter expert and trainer.

The role emphasizes collaboration, policy adherence, and leveraging NLP tools to support compliant documentation and coding.

Qualifications

• Associate degree or better in nursing, HIM or a related field.
• Minimum six years acute care clinical documentation experience.
• Familiarity with Medicare/Medicaid and commercial payer regulations.
• Knowledge of ICD-10-CM/PCS coding.
• Ability to perform independent queries.

Responsibilities

• Review records for quality and accuracy of documentation to reflect severity and codes.
• Provide ongoing education to providers via various channels.
• Identify documentation improvement opportunities and discuss with providers.
• Develop clear queries and use NLP tools to assist coding and reporting.
• Report KPIs to Medical Executive Committee and related bodies.
• Train and onboard new staff and participate in special projects.

Skills

Clinical knowledge

Coding skills

Documentation improvement

MS Office

Cerner EHR

Optum 360 eCAC

Analytical thinking

Interpersonal skills

Writing skills

Education

Associate’s Degree in Nursing/HIM or related field

Tools

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.

Summary

The Clinical Documentation Specialist Senior 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 hierarchal condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with providers. The Senior level is expected to function as a subject matter expert on the team and assist less experience team members in understanding and following operational policies. This role is responsible for training and onboarding new team members and participating in special projects assigned by the Mid Revenue Cycle leadership.The Clinical Documentation Specialist Senior 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 on-site meetings, zoom meetings, telephonic discussions, rounding and email. Additionally, the Clinical Documentation Specialist Senior will collaborate with the Health Information Management (HIM) coding staff and the Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting outcomes is complete and accurate.

Responsibilities

• Reviews medical records for quality, completeness, and accuracy of documentation. Ensures that coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality. Identifies gaps in documentation as well as conflicting or unspecified diagnoses and clarifies diagnoses with providers to assign the most accurate ICD 10CM/PCS code from the documentation. Must meet and maintain the quality and productivity measures established per polices.
• Delivers ongoing education to providers through collaboration and communication via on-site meetings, zoom meetings, telephonic discussions, rounding, and email. Provides supplemental educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians.
• Identify and share documentation improvement opportunities with providers to capture the patient’s accurate severity of illness and risk of mortality, comorbid conditions, and all other condition categories.
• Develop clear, concise and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non specified documentation. Utilizes software system and the Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely.
• Key Performance Indicators and additional significant metrics will be reported and discussed regularly, and as needed to the Medical Executive Committee via presentation to the Medical Records Committee and with other committees as directed
• The Senior is expected to function as a subject matter expert on the team and assist less experience team members on following operational policies. It is responsible for training and onboarding new team members and participating in special projects assigned by the Mid Revenue Cycle leadership.

Credentials and Experience

• Associate’s Degree – field of study: Nursing, HIM or another Healthcare related field
• A minimum six (6) 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 queriesER

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

Preferred Experience

4 years’ experience in oncology

Vizient experience

Salary Range

$80,974.40 - $123,364.80

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.

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.

Reasonable Accommodation

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