Clinical Documentation Specialist: Elevate Care & Compliance

University of Miami; United States; Remote; USD 75,000 - 95,000; Full time

Job summary

The University of Miami Health System seeks a Clinical Documentation Specialist I (CDI I) to perform clinically based concurrent and retrospective reviews of inpatient records. You will facilitate accurate documentation for severity of illness and quality, interacting with physicians, HIM, and nursing staff.

The role supports CMS/regs, improves reimbursement, and participates in CDMP education. Requires a Bachelor’s in Nursing or Health Information Management, with CCDS/CDIP preferred and 2+

Qualifications

• Bachelor’s degree in Nursing, Health Information Management, or related medical field required.
• CCDS or CDIP certification preferred; must obtain within 3 years of hire.
• At least 2 years direct patient care in acute care or 3 years inpatient coding experience required.
• Experience with 3M 360 Encompass preferred.
• Proficiency in clinical documentation improvement and data abstraction.

Responsibilities

• Reviews medical records and identifies potential gaps in clinical documentation.
• Performs initial, concurrent review and follow-ups as directed.
• Assigns working DRG based on principal diagnosis and procedures, including POA indicators.
• Queries physicians within established timelines to clarify documentation.
• Reconciles CDI-assigned DRG with final coded DRG and escalates as needed.
• Educates staff and participates in meetings to improve documentation practices.

Skills

Clinical documentation

Query physicians

Critical thinking

Interpersonal skills

Documentation improvement

Data analysis

Education

Bachelor’s degree in Nursing or Health Information Management

Related medical field

Tools

3M 360 Encompass

Microsoft Office

Job description

The University of Miami Health System seeks a Clinical Documentation Specialist I (CDI I) to perform clinically based concurrent and retrospective reviews of inpatient records. You will facilitate accurate documentation for severity of illness and quality, interacting with physicians, HIM, and nursing staff.

The role supports CMS/regs, improves reimbursement, and participates in CDMP education. Requires a Bachelor’s in Nursing or Health Information Management, with CCDS/CDIP preferred and 2+