Clinical Documentation Specialist IThe Clinical Documentation Specialist I (CDI) provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. The CDI I facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Compliant Documentation Management Program (CDMP) process is a key role. Facilitates appropriate physician documentation of care to accurately reflect patientseverity of illness and risk mortality. Obtains accurate and compliant reimbursement for acute care services and reports quality of care outcomes. Collects data regarding timeliness of report completion to assist physicians in meeting applicable rules and regulations. Verifies the documentation of the correct admission type and follows up on incorrect assignments immediately. Directs clinical documentation improvement and data abstraction. Ensures accurate and timely reviews of inpatient records. Adheres to University and unit-level policies and procedures and safeguards University assets.
Education:
Bachelor's degree in Nursing, Health Information Management, or related medical field required. Graduate Foreign Medical degree will be considered. Certification and Licensing: Current RN, MD or RHIA requiredCCDS or CDIP certification preferred; shall obtain CCDS or CDIP within 3 years from date of hire Coding certification (CCS, CIC, or CPC) preferred
Experience:
At least two (2) years direct patient care in acute care setting or (3) years inpatient coding experience required. Prior clinical documentation improvement (CDI) experience preferred. Demonstrated extensive clinical knowledge, critical-thinking skills, and understanding of disease processes, anatomy, pathophysiology, and disease management/treatment required. Proficiency with Microsoft Office (Excel, PowerPoint, Word, Outlook) required. Proficiency with technology/software required. Experience with 3M 360 Encompass preferred. Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers. The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.
