Clinical Documentation Strategist

University of Miami; Town of Florida (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

University of Miami is seeking a Clinical Documentation Specialist I to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation for severity of illness, quality, and appropriate reimbursement. The role requires strong clinical judgment, physician collaboration, and the ability to query for clarifications within regulatory timelines.

The CDI I will work with physicians, HIM professionals, and nursing staff, participate in education efforts, and help

Qualifications

• Clinical documentation specialist role involving inpatient records review.
• Ability to identify documentation gaps and drive denials/queries.
• Strong collaboration with physicians and health information management staff.

Responsibilities

• Review medical records and identify potential gaps in clinical documentation.
• Perform initial and concurrent reviews and follow-ups on assigned populations.
• Assign DRG based on diagnosis, co-morbid conditions, and/or procedures.
• Ensure documentation supports diagnoses and coding; document reviews in designated systems.
• Query physicians within timelines for clarification of documentation.
• Educate staff on CDI processes and documentation requirements.
• Collaborate with HIM staff to resolve DRG discrepancies and coding issues.
• Participate in team meetings and educational opportunities.
• Collect data on timeliness of report completion for regulatory compliance.

Skills

Interpersonal skills

Clinical judgement

Query management

Communication with physicians

Job description

University of Miami is seeking a Clinical Documentation Specialist I to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation for severity of illness, quality, and appropriate reimbursement. The role requires strong clinical judgment, physician collaboration, and the ability to query for clarifications within regulatory timelines.

The CDI I will work with physicians, HIM professionals, and nursing staff, participate in education efforts, and help