Clinical Documentation Specialist: Elevate Patient Care

NurseRemotely; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

The University of Miami Health System is seeking a Clinical Documentation Specialist I (CDI I) to perform concurrent and retrospective reviews of inpatient records. The role focuses on accurate documentation of severity of illness and risk mortality, with collaboration across physicians, HIM, and nursing staff.

Responsibilities include querying providers, ensuring clinical support for diagnoses, DRG reconciliation, and staff education through the CDMP process.

Qualifications

• Bachelor's degree in Nursing, Health Information Management, or related medical field required.
• RN, MD or RHIA active license/certification required; CCDS/CDIP preferred; CCDS/CDIP within 3 years.
• Two years direct patient care in acute care or three years inpatient coding experience required.

Responsibilities

• Facilitates appropriate physician documentation of care to reflect patient severity of illness and risk mortality.
• Reviews medical records and identifies gaps in clinical documentation for all patient types and payer populations.
• Performs initial, concurrent review and follow up on assigned population.
• Assigns working DRG based on principal diagnosis, complications, or co-morbid conditions with POA indicators.
• Ensures documented conditions and codes are clinically supported, with timely documentation in systems.
• Queries physicians within established timelines for missing or inconsistent documentation.
• Interacts with physicians to complete/resolve queries prior to discharge.
• Reconciles CDI-assigned DRG against final coded DRG and escalates mismatches per protocol.
• Educates health-care team about documentation regulations and guidelines.

Skills

Interpersonal skills

Critical thinking

Clinical knowledge

Effective communication

Education/mentorship

Education

Bachelor's degree in Nursing or HIM

Graduate Foreign Medical degree considered

Tools

Microsoft Office

3M 360 Encompass

Job description

The University of Miami Health System is seeking a Clinical Documentation Specialist I (CDI I) to perform concurrent and retrospective reviews of inpatient records. The role focuses on accurate documentation of severity of illness and risk mortality, with collaboration across physicians, HIM, and nursing staff.

Responsibilities include querying providers, ensuring clinical support for diagnoses, DRG reconciliation, and staff education through the CDMP process.