Moffitt Cancer Center
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CLINICAL DOCUMENTATION SPECIALIST SR
role at
Moffitt Cancer Center .
Position Overview The Clinical Documentation Specialist Senior is responsible for facilitating improvement in the overall quality and completeness of provider‑based clinical documentation in the medical record by working directly with providers. This position assists 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.
The Specialist assesses clinical documentation through extensive medical record review, deployment of artificial intelligence, and collaboration directly with providers to clarify documentation to accurately and completely reflect patient’s medical conditions. Extensive collaboration with physicians, mid‑levels, nursing staff, and other patient care givers includes developing and delivering education via on‑site meetings, Zoom meetings, telephonic discussions, rounding and email. The role collaborates with the Health Information Management (HIM) coding staff and educators to ensure appropriate reimbursement and complete, accurate clinical information for profiling and reporting outcomes.
Additionally, the Specialist functions as a subject matter expert on the team, assisting less experienced 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.
Responsibilities
Reviews medical records for quality, completeness, and accuracy of documentation. Ensures coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality. Identifies gaps in documentation and clarifies diagnoses with providers to assign the most accurate ICD-10-CM/PCS code. Meets and maintains quality and productivity measures established per policies.
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.
Identifies and shares 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.
Develops clear, concise, and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non‑specified documentation. Utilizes software system and Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely.
Reports key performance indicators and additional significant metrics regularly and as needed to the Medical Executive Committee via presentations to the Medical Records Committee and other committees as directed.
Functions as a subject matter expert on the team and assists less experienced team members in following operational policies. 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 in Nursing, Health Information Management, or another healthcare‑related field.
Minimum six (6) years of acute‑care clinical documentation experience.
ICD-10-CM and ICD-10-PCS coding and query process knowledge.
Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers to address them.
Proficient in computer skills including MS Office, Optum 360 eCAC, Cerner HER.
Certifications
Certified Clinical Documentation Specialist (CCDS) from ACDIS.
Certified Documentation Integrity Practitioner (CDIP) from AHIMA.
Certified Documentation Expert Inpatient (CDEI) from AAPC.
Registered Nurse (RN) in lieu of a listed certification; an active RN will satisfy the certification requirement.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
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CLINICAL DOCUMENTATION SPECIALIST SR
role at
Moffitt Cancer Center .
Position Overview The Clinical Documentation Specialist Senior is responsible for facilitating improvement in the overall quality and completeness of provider‑based clinical documentation in the medical record by working directly with providers. This position assists 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.
The Specialist assesses clinical documentation through extensive medical record review, deployment of artificial intelligence, and collaboration directly with providers to clarify documentation to accurately and completely reflect patient’s medical conditions. Extensive collaboration with physicians, mid‑levels, nursing staff, and other patient care givers includes developing and delivering education via on‑site meetings, Zoom meetings, telephonic discussions, rounding and email. The role collaborates with the Health Information Management (HIM) coding staff and educators to ensure appropriate reimbursement and complete, accurate clinical information for profiling and reporting outcomes.
Additionally, the Specialist functions as a subject matter expert on the team, assisting less experienced 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.
Responsibilities
Reviews medical records for quality, completeness, and accuracy of documentation. Ensures coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality. Identifies gaps in documentation and clarifies diagnoses with providers to assign the most accurate ICD-10-CM/PCS code. Meets and maintains quality and productivity measures established per policies.
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.
Identifies and shares 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.
Develops clear, concise, and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non‑specified documentation. Utilizes software system and Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely.
Reports key performance indicators and additional significant metrics regularly and as needed to the Medical Executive Committee via presentations to the Medical Records Committee and other committees as directed.
Functions as a subject matter expert on the team and assists less experienced team members in following operational policies. 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 in Nursing, Health Information Management, or another healthcare‑related field.
Minimum six (6) years of acute‑care clinical documentation experience.
ICD-10-CM and ICD-10-PCS coding and query process knowledge.
Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers to address them.
Proficient in computer skills including MS Office, Optum 360 eCAC, Cerner HER.
Certifications
Certified Clinical Documentation Specialist (CCDS) from ACDIS.
Certified Documentation Integrity Practitioner (CDIP) from AHIMA.
Certified Documentation Expert Inpatient (CDEI) from AAPC.
Registered Nurse (RN) in lieu of a listed certification; an active RN will satisfy the certification requirement.
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
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