Job Description

Job Description Summary Remote/Hybrid - Florida Residency Required. The Clinical Documentation Specialist II improves the accuracy and quality of inpatient medical record documentation to ensure correct DRG assignment, coding integrity, and optimized reimbursement. The role includes timely chart reviews, identification of documentation gaps, and issuance of clinically sound queries with high response and agreement rates. This specialist collaborates closely with providers and interdisciplinary teams, maintains accurate data in 3M 360 and Epic, supports financial and quality review projects, mentors new staff, and assists Rehab services with compliance and tier optimization. Strong clinical reasoning, ICD‑10/DRG knowledge, and communication skills are essential. Responsibilities Applies ICD-10 coding guidelines appropriately and has an 85% working DRG accuracy. Has good working knowledge of all DRG and their structure, as well as CCs and MCCs. Can discern what the impact of a query would be in order to focus efforts efficiently and determine priorities. Reviews all patient records in his/her assigned unit(s) between 24-48 hours of inpatient admission and subsequently between 2-3 days until discharge, as needed; manages approximately 16-20 charts daily. Recognizes opportunities for documentation improvement by utilizing sound clinical reasoning and critical thinking skills, as well as coding concepts. Formulates clinically credible queries to physicians and achieves a response rate and agree rate above 85% respectively. Maintains excellent rapport and working relationship with physicians, residents, physician assistants, nurse practitioners, nurses, case managers and other healthcare providers. Maintains query rate of 25-35% of all patient records reviewed. Follows up on all pending queries on a daily basis until answered and monitors. Manages the Epic query workqueues as well as the 3M 360 pending queries swim lanes regularly. Has good command of 3M 360 Encompass software and maintains accurate data input of patient's working DRG and baseline DRG. Records daily review notes and all other notes required within the software accurately. Responsible for retrospective reviews for quality and revenue projects as assigned. Properly documents query narrative and notes the expected query response and the actual response including date and location of response in the medical record (what and where). Responsible for mentoring and training new employees in conjunction with department manager. Reviews the mismatch report periodically to ensure working DRGs are optimal and addresses any discrepancies with HIM coding staff in an effective and timely manner. Supports manager in reconciling monthly query reports and other financial reports as needed. Works individual monthly financial report to ensure accounts with financially impacting queries have the proper baseline DRG and that final DRG and working DRG match to ensure reporting is optimal. Reports accounts with unanswered queries that would have otherwise impacted DRG weight for tracking. Provides support to Rehab team by reviewing potential rehab admissions to ensure they meet CMS compliance criteria and queries Rehab physicians as needed to include supporting diagnoses and evaluates rehab visits for potential tier improvements by querying physicians for potential qualifying diagnoses. Qualifications Remote/Hybrid - Florida Residency Required. License/Registration/Certification: R.N. or Medical Graduate. Education: R.N. Certified preferred; Medical School Graduate; Bachelor's Degree. Experience: Critical Care/Intensive Care patient care experience preferred; medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired. Benefits Health benefits Life insurance Long-term disability coverage Healthcare spending accounts Retirement plan Paid time off Pet Insurance Tuition reimbursement Employee assistance program Wellness program On-site housing for select positions and more! #J-18808-Ljbffr Mount Sinai Medical Center

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