Clinical Documentation Specialist I: Elevate Care & Reimbursement

University of Miami; Florida; On-site; USD 65,000 - 85,000; Full time

Job summary

The University of Miami seeks aClinical Documentation Specialist I (CDI I) to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation for severity of illness and quality. You will interact with physicians, HIM and nursing staff, and contribute to CDMP education and process improvements across the team.

Qualified candidates have a nursing, HIM or related medical background with relevant CDI experience, and familiarity with DRG systems.

Qualifications

• Bachelor's degree in Nursing, Health Information Management, or related medical field required.
• Current RN, MD or RHIA required.
• CCDS or CDIP certification preferred; shall obtain CCDS or CDIP within 3 years from date of hire.
• At least two years direct patient care in acute care setting or 3 years inpatient coding experience required.
• Proficiency with Microsoft Office; experience with 3M 360 Encompass preferred.

Responsibilities

• Review inpatient records to evaluate documentation and utilization for acute care services.
• Facilitate accurate documentation of severity of illness and quality in the chart.
• Query physicians for conflicting or incomplete documentation within established timelines.
• Ensure documentation supports DRG assignments and reimbursement appropriately.
• Participate in meetings and staff education on CDI processes and CDMP.

Skills

Communication skills

Critical thinking

Team collaboration

Education/Training

Education

Bachelor's degree in Nursing or Health Information Management

Graduate Foreign Medical degree considered

CCDS or CDIP certification (preferred; obtain within 3 years)

Tools

Microsoft Office

3M 360 Encompass

Job description

The University of Miami seeks aClinical Documentation Specialist I (CDI I) to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation for severity of illness and quality. You will interact with physicians, HIM and nursing staff, and contribute to CDMP education and process improvements across the team.

Qualified candidates have a nursing, HIM or related medical background with relevant CDI experience, and familiarity with DRG systems.