Clinical Documentation Specialist I: Elevate Patient Records

University of Miami; Florida; On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical benefits

Tuition remission

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Clinical documentation

Interpersonal skills

Medical record review

Communication

Education

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

Tools

Microsoft Office

3M 360 Encompass

Job description

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.