The Clinical Documentation Specialist Senior is responsible for improving the quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This role helps ensure documentation accurately reflects severity of illness, risk of mortality, complexity of patient care, and condition categories.
The position reviews clinical documentation using medical record review, clinical judgment, artificial intelligence tools, and collaboration with providers to clarify documentation. It also supports compliance with AHIMA and ACDIS standards, keeps current with coding updates, and works closely with physicians, nursing staff, HIM coding staff, and educators.
In addition, this senior-level role serves as a subject matter expert, assists less experienced team members, supports onboarding and training, and participates in special projects for Mid Revenue Cycle leadership.
Required Experience and Education
- Associate’s degree in Nursing, HIM, or another healthcare-related field
- Minimum 6 years of acute care clinical documentation experience
Required Knowledge and Skills
- Experience with Medicare, Medicaid, and commercial payer regulations
- Knowledge of healthcare regulations and coding guidelines
- Strong understanding of ICD-10-CM and ICD-10-PCS coding
- Experience performing independent queries
- Ability to identify documentation improvement opportunities and communicate effectively with providers
- Strong analytical, organizational, interpersonal, and writing skills
- Critical thinking, problem-solving, and deductive reasoning abilities
- Proficiency with MS Office, Optum 360 eCAC, and Cerner EHR
- Knowledge of healthcare regulatory environment and clinical documentation management strategies
- Understanding of Case Mix Index and its impact
- Flexibility to work around clinician schedules
Certifications
- CCDS, CDIP, or CDEI certification preferred
- Active RN license may substitute for certification requirement
Preferred Experience
- 4 years of oncology experience
- Vizient experience
Location
Tampa, Florida, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
No
Posted
3 weeks ago