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 10,000 who are shaping the future we envision. Moffitt has been recognized as a Best and Brightest Company to Work for in the Nation, a Digital Health Most Wired Organization and continually named one of the Tampa Bay Time's Top Workplaces. A National Cancer Institute (NCI)-designated Comprehensive Cancer Center since 2001.
Job Summary
The Clinical Documentation Specialist Senior is a 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.
Position Highlights
• 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 accurate. • 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 leadership.
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 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. Identify and share documentation improvement opportunities with providers to capture the patients 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
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.
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 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 the opportunities in documentation. Proficient in computer skills including: MS Office, Optum 360 eCAC, Cerner HER
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)
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
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.