CLINICAL DOCUMENTATION SPECIALIST SR (CDI)

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 11,000 who are shaping the future we envision. Moffitt has been recognized as a Best and Brightest Company to Work For in the Nation and is continually named one of the Tampa Bay Times’ Top Workplaces. Summary 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 ensures that documentation accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchical condition categories of the patient. The Senior level functions as a subject matter expert on the team and assists less experienced team members in understanding and following operational policies. The role includes training and onboarding new team members, participating in special projects assigned by Mid Revenue Cycle leadership, and conducting independent research to ensure compliance with evolving standards from AHIMA and ACDIS. 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‑10‑CM/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. 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 the Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely. Reports and discusses Key Performance Indicators and additional significant metrics regularly, and as needed to the Medical Executive Committee via presentation to the Medical Records Committee and with 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. Qualifications Associate’s Degree – field of study: Nursing, HIM, or another Healthcare related field. A minimum of six (6) years of acute care clinical documentation experience, including applying Medicare, Medicaid and Commercial payer regulations, charging and coding guidelines, healthcare regulations, ICD‑10‑CM, ICD‑10‑PCS coding, and performing independent queries. ER 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. 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 and clinical documentation management strategies. Must be flexible to accommodate clinician schedules. Knowledge of Case Mix Index and how it is influenced. Preferred: 4 years’ experience in oncology Vizient experience. Salary Range $82,934.80 - $126,427.60 Salary 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. Moffitt Career Site If you have the vision, passion, and dedication to contribute to our mission, then we have a place for you! 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. 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