Clinical Documentation Specialist SR or CDI Level II

At Moffitt Cancer Center, we strive to be the leader in understanding the complexity of cancer and applying these insights to contribute to the prevention and cure of cancer. Our diverse team of over 9,000 are dedicated to serving our patients and creating a workspace where every individual is recognized and appreciated. For this reason, Moffitt has been recognized on the 2023 Forbes list of America’s Best Large Employers and America’s Best Employers for Women, Computerworld magazine’s list of 100 Best Places to Work in Information Technology, DiversityInc Top Hospitals & Health Systems and continually named one of the Tampa Bay Time’s Top Workplace. Additionally, Moffitt is proud to have earned the prestigious Magnet® designation in recognition of its nursing excellence. Moffitt is a National Cancer Institute-designated Comprehensive Cancer Center based in Florida, and the leading cancer hospital in both Florida and the Southeast. We are a top 10 nationally ranked cancer center by Newsweek and have been nationally ranked by U.S. News & World Report since 1999. Working at Moffitt is both a career and a mission: to contribute to the prevention and cure of cancer. Join our committed team and help shape the future we envision. Summar yClinical Documentation Specialist S RThe IDEAL Candidate will have previously served as a Clinical Documentation Specialist . Position Highlight • s: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 patien • t.The Clinical Documentation Specialist Senior assesses clinical documentation through extensive medical record review, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. 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. This position 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 accurat • e.Additionally, the Clinical Documentation Specialist Senior 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 leadershi p. Responsibiliti • es: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 polic • es.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 clinicia • ns.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 categori • es.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 time • ly.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 direc • tedThe 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 leadersh ip. Credentials and Experie • nce:Associate’s Degree – field of study: HIM, Nursing or another Healthcare related f • ieldA minimum six (6) years acute care clinical documentation experience to incl • ude:Applying Medicare, Medicaid and Commercial payer regulations, charging and coding guidel • ines• Healthcare regulat • ions• ICD-10-CM, ICD-10-PCS co • ding• Performing independent que ries Certificat • ions:(CCDS) Certified Clinical Documentation Specialists from • ACDIS(CDIP) Certified Documentation Integrity Practitioner from • AHIMA(CDEI) Certified Documentation Expert Inpatient from • AAPCRegistered Nurse (RN) *in lieu of a certification listed above, an (active) RN will satisfy the certification requir ement The Clinical Documentation Special ist IIThe 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 hierarchal condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with prov iders. 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 O ctober.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 II 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 ac curate. Minimum Experience RequiredA minimum of four (4) years' acute care clinical documentation experience to include:• Applying Medicare, Medicaid and Commercial payer regulations, charging and coding gu idelines• Healthcare reg ulations• ICD-10-CM, ICD-10-PC S coding• Performing independent queries Certif • ications:(CCDS) Certified Clinical Documentation Specialists f • rom ACDIS(CDIP) Certified Documentation Integrity Practitioner f • rom AHIMA(CDEI) Certified Documentation Expert Inpatient • from AAPCRegistered Nurse (RN) *in lieu of a certification listed above, an (active) RN will satisfy the certification req uirement. Apply tot his job