Senior Clinical Documentation Specialist Oncology & AI

Moffitt Cancer Center; United States; Remote; USD 81,000 - 123,000; Full time

Job summary

Moffitt Cancer Center seeks a Senior Clinical Documentation Specialist to improve provider-based documentation quality and accuracy in the medical record. You will work with treating providers to ensure documentation reflects severity of illness, risk of mortality, and care complexity, while guiding ICD-10-CM/PCS coding and NLP-assisted review.

The role requires subject-matter expertise, training of new staff, and collaboration with HIM coding and educators to optimize reimbursement and outcomes

Qualifications

• 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.

Responsibilities

• Reviews medical records for quality, completeness, and accuracy of documentation.
• Delivers ongoing education to providers through collaboration and communication via on-site meetings, zoom meetings, telephonic discussions, rounding, and email.
• 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.
• Key Performance Indicators and additional significant metrics will be reported to Medical Executive Committee and other committees.
• Function as a subject matter expert and assist less experienced team members; training and onboarding new staff.

Skills

MS Office

Cerner EHR

Strong writing skills

Analytical

Critical thinking

Problem solving

Education

Associate’s Degree – Nursing, HIM or Healthcare related field

Tools

Optum 360 eCAC

Job description

Moffitt Cancer Center seeks a Senior Clinical Documentation Specialist to improve provider-based documentation quality and accuracy in the medical record. You will work with treating providers to ensure documentation reflects severity of illness, risk of mortality, and care complexity, while guiding ICD-10-CM/PCS coding and NLP-assisted review.

The role requires subject-matter expertise, training of new staff, and collaboration with HIM coding and educators to optimize reimbursement and outcomes