CDI Specialist: Elevate Patient Documentation & Compliance

University of Miami; Florida; Hybrid; USD 70,000 - 100,000; Full time

Job summary

The University of Miami seeks a Clinical Documentation Specialist I to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation of severity of illness and quality of care. You will collaborate with physicians, HIM professionals, and nursing staff to support compliant documentation and reimbursement.

This role emphasizes timely documentation, DRG accuracy, and educating care teams on CDMP processes, contributing to quality outcomes and regulatory

Qualifications

• Bachelor’s degree in Nursing, Health Information Management, or related medical field required.
• RN, MD or RHIA certification required; CCDS or CDIP preferred and to be obtained within 3 years.
• Minimum 2 years direct patient care in acute care or 3 years inpatient coding experience.
• Proficiency with Microsoft Office; experience with 3M 360 Encompass preferred.
• Strong clinical knowledge and understanding of disease processes.

Responsibilities

• The CDI I reviews inpatient medical records concurrently and retrospectively to evaluate documentation and utilization of acute care services.
• Facilitates accurate documentation of severity of illness and quality in the medical record.
• Queries physicians within established timelines for conflicting or incomplete documentation.
• Ensures documented conditions and coded diagnoses are clinically supported with chart evidence.
• Assigns working DRG based on principal diagnosis, complications, or comorbid conditions, including POA indicators.
• Performs timely reconciliation of CDI-assigned DRG against final coded DRG and escalates mismatches.
• Educates staff on documentation strategies and participates in education tools and sessions.
• Collaborates with HIM and nursing staff to resolve discrepancies and improve coding accuracy.
• Documents reviews in designated systems by established deadlines; participates in team meetings and educational opportunities.

Job description

The University of Miami seeks a Clinical Documentation Specialist I to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation of severity of illness and quality of care. You will collaborate with physicians, HIM professionals, and nursing staff to support compliant documentation and reimbursement.

This role emphasizes timely documentation, DRG accuracy, and educating care teams on CDMP processes, contributing to quality outcomes and regulatory