Clinical Documentation Specialist 1

University of Miami; Florida; Presencial; USD 65 000 - 90 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical benefits

Tuition remission

Resumo da oferta

The University of Miami seeks a Clinical Documentation Specialist I (CDI I) to review inpatient records for accurate documentation of illness severity and risk of mortality. The role includes physician collaboration, education, and DRG integrity to support compliant reimbursement.

Key responsibilities include concurrent reviews, querying as needed, and partnering with HIM staff to ensure timely, accurate documentation and adherence to CDMP processes.

Qualificações

• Bachelor's degree required in Nursing, Health Information Management, or related medical field.
• Clinical documentation knowledge and critical-thinking skills required.
• Experience in acute care CDI preferred.

Responsabilidades

• Perform concurrent and retrospective reviews to ensure accurate documentation for severity of illness and risk of mortality.
• Query physicians when clarification is needed and document responses.
• Collaborate with physicians and HIM staff to improve DRG accuracy and reimbursement.

Conhecimentos

Clinical documentation

Interpersonal skills

Medical record review

Communication

Formação académica

Bachelor's degree in Nursing/Health Information Management or related field

Ferramentas

Microsoft Office

3M 360 Encompass

Descrição da oferta de emprego

The Clinical Documentation Specialist I (CDI) provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services.

The CDI I facilitate accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Compliant Documentation Management Program (CDMP) process is a key role. Facilitates appropriate physician documentation of care to accurately reflect patient severity of illness and risk mortality. Obtains accurate and compliant reimbursement for acute care services and reports quality of care outcomes. Collects data regarding timeliness of report completion to assist physicians in meeting applicable rules and regulations. Verifies the documentation of the correct admission type and follows up on incorrect assignments immediately. Directs clinical documentation improvement and data abstraction. Ensures accurate and timely reviews of inpatient records. Adheres to University and unit-level policies and procedures and safeguards University assets. Facilitates appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality.

• Reviews medical records and identifies potential gaps in clinical documentation for all assigned patient

types and payer populations as directed on admission and throughout the hospitalization.

• Performs initial, concurrent review and follow up on assigned population consistent with department

volume and frequency requirements.

• Assigns working DRG based upon identification and selection of principal diagnosis, complications, or

co-morbid conditions and/or valid OR procedures, including capture of POA indicators.

• Ensures documented conditions, clarifications, and coded diagnoses are clinically supported.
• Documents reviews and other pertinent information in designated systems by established deadlines.
• Uses clinical judgement to determine when and/or if a query is necessary.
• Queries physicians within established timelines via approved query forms for conflicting, imprecise,

incomplete, illegible, or inconsistent documentation by requesting and obtaining additional documentation within the health record when appropriate.

• Uses clinical judgement to determine appropriate and relevant clinical indicators and to discern

appropriate reasonable diagnostic options when formulating non-standard queries.

• Interacts with Physicians to complete/resolve queries prior to patient discharge.
• Performs timely reconciliation of CDI-assigned DRG against final coded DRG.
• Escalates DRG mismatches as appropriate per established departmental protocols.
• Develops collaborative relationships to facilitate accomplishment of work goals.
• Possesses excellent interpersonal skills in building, negotiating, and maintaining crucial relationships.
• Demonstrates a willingness and ability to assist others.
• Understands and supports documentation strategies (upon completion of training) and continues to

educate self and team members using educational tools, videos and provided WebEx's.

UNIVERSITY OF MIAMI

Core_Clinical Documentation Specialist 1

• Recognizes opportunities for documentation improvement using strong clinical skills/knowledge.
• Uses critical thinking and sound judgment in decision making for reimbursement considerations in

balance with regulatory compliance.

• Strategically educates members of the patient-care team regarding documentation regulations and

guidelines, including house staff, attending physicians, allied health practitioners, nursing, and care

• Effectively and appropriately communicates with physicians and other healthcare providers as necessary

to ensure appropriate, accurate and complete clinical documentation.

• Communicates with HIM staff and collaborates with them to resolve discrepancies with DRG

assignments and other coding issues.

• Complete well-timed follow-up case reviews (and secondary reviews as needed) on all concurrent cases

with priority given for resolution of those with clinical documentation clarifications.

• Participate in meetings, including feedback on outstanding issues, presentations for educational

opportunities and any other needs identified.

• Other duties may be assigned.
• Collects data regarding timeliness of report completion to assist physicians in meeting applicable rules

and regulations.

• Verifies the documentation of the correct admission type and follows up on incorrect assignments

immediately.

• Adheres to University and unit-level policies and procedures and safeguards University assets.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

Education

Bachelor's degree in Nursing, Health Information Management, or related medical field required. Graduate Foreign Medical degree will be considered.

Certification and Licensing

Current RN, MD or RHIA required

CCDS or CDIP certification preferred; shall obtain CCDS or CDIP within 3 years from date of hire

Coding certification (CCS, CIC, or CPC) preferred

Experience

At least two (2) years direct patient care in acute care setting or (3) years inpatient coding experience required. Prior clinical documentation improvement (CDI) experience preferred.

Demonstrated extensive clinical knowledge, critical-thinking skills, and understanding of disease processes, anatomy, pathophysiology, and disease management/treatment required.

Proficiency with Microsoft Office (Excel, PowerPoint, Word, Outlook) required.

Proficiency with technology/software required. Experience with 3M 360 Encompass preferred.

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

• including medical, dental, tuition remission and more

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

Job Status

Full time

Employee Type

Staff