Clinical Documentation Specialist II

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.

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 October.

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 accurate.

Essential Functions:

• Performs extensive record reviews.
• Provider Communcation and Education.
• Documentation Improvement.
• Compliance and Query Development.
• Report clinical documentation improvement metrics.
• Perform other duties as assigned.

Experience and Education:

• Associate's Degree 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.
• **Any (one) of the following certifications is required:
  • (CCDS) Certified Clinical Documentation Specialists from ACDIS.
  • (CDIP) Certified Documentation Integrity Practitioner from AHIMA.
  • (CDEI) Certified Documentation Expert Inpatient from AAPC.
  • *in lieu of a certification listed above, an (active) RN will satisfy the certification requirement/ Registered Nurse (RN) Governing Body Website:
• Florida Board of Nursing
• (AHIMA) American Health Information Management Association
• (ACDIS) Association of Clinical Documentation Integrity Specialists
• (AAPC) American Academy of Professional Coders

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.