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The Clinical Documentation Specialist II facilitates the improvement of clinical documentation quality by collaborating directly with providers to ensure medical records accurately reflect patient severity and complexity. This role involves conducting extensive medical record reviews, developing provider queries, and delivering education to clinical staff.
Summary
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 hierarchal condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with providers.
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
Preferred Experience
2 years of experience in oncology
Vizient experience
Salary Range
$82,934.80 - $126,427.60Salary 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.
1. 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.
2. Reasonable Accommodation
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. Moffitt endeavors to make moffitt.org/careers accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact one of the Human Resources receptionists by phone at 813-745-7899 or by email at HRReceptionists@moffitt.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.
Read more information about your EEO rights under the law.
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