Clinical Documentation Specialist

March 13

🐊 Florida – Remote

Although this job is listed in Florida, this company may be open to hiring remote in other states.

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

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University of Miami

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University of Miami is a prestigious private research university located in Coral Gables, Florida. It offers a wide range of undergraduate, graduate, and professional degree programs through its numerous schools and colleges, including the School of Architecture, College of Arts and Sciences, and Miami Herbert Business School among others. The university is recognized for its contributions to research, particularly in areas such as marine and atmospheric science through the Rosenstiel School, as well as in medicine through the Miller School of Medicine. The institution is also noted for its vibrant student life, with a strong emphasis on athletics and community engagement. University of Miami is committed to fostering an inclusive educational environment and is home to a diverse student body from around the globe.

10,000+ employees

Founded 1925

📚 Education

💰 $1M Grant on 2023-02

📋 Description

• Performs clinically based health record reviews to facilitate and obtain appropriate provider documentation for clinical conditions and procedures to reflect severity of illness, accurate coding/DRG, expected risk of mortality, accuracy of patient outcomes, and complexity of patient care. • Through compliant query processes and education, clarifies incomplete, conflicting, ambiguous, and/or missing provider documentation. • Works in collaboration with other CDI Specialists, coders, quality analysts, providers, and other members of the healthcare team to ensure accurate, high-quality clinical documentation to support UHealth initiatives. • Adheres to departmental and organizational goals, objectives, standards of performance, policies and procedures, continually ensuring quality documentation and regulatory compliance. • Ensures accuracy, completeness, and quality of clinical information used for measuring and reporting physician and hospital outcomes. • Performs thorough and timely medical record reviews to identify potential gaps or opportunities to facilitate improved provider documentation. • Follows designated case review workflows, including initial, continued stay, retrospective, and final CDI reviews. • Ensure clinical documentation accurately reflects the level of care rendered, severity of illness, risk of mortality, and clinical validation (in compliance with government and other regulations). • Demonstrates proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG by assigning accurate working DRGs based upon identification and selection of principal diagnosis, complications, co-existing or co-morbid conditions, POA indicators, and significant procedures. • Ensures documented conditions, clarifications, and coded diagnoses are clinically supported. • Follows up on queries per policy, including reviewing for continued appropriateness and updating pending queries as needed. • Recognizes opportunities for documentation improvement using strong critical-thinking skills and sound judgment in decision making, keeping integrity and compliance at the forefront of considerations in addition to outcomes, reimbursement, and regulatory requirements. • Facilitates high-quality documentation by utilizing queries that are effective, clear, concise, and compliant in accordance with latest AHIMA/ACDIS Query Practice Brief. • Makes recommendation of possible refinement of principal diagnosis, secondary diagnoses, and/or procedures based on clinical data to facilitate appropriate DRG assignment. • Records review findings and other data elements timely and accurately into CDI Software and other data mechanisms to support data integrity for reporting. • Effectively and appropriately communicates and collaborates with providers, HIM/coding, quality, CDI, and other members of the healthcare team. • Professionally interacts with providers to complete/resolve queries, provide education, and/or answer questions as needed. • Escalates concerns with query responses, DRG reconciliation, notifications, etc. as appropriate or per departmental protocol. • Performs timely reconciliation of working codeset/DRG compared to final codeset/DRG. Effectively communicate discrepancies with coding, including rationale and supporting evidence. Escalate as appropriate. • Demonstrates willingness to learn and accepts feedback productively. • Meets and maintains CDI quality and query compliance standards. • Works independently; demonstrates effective time management and prioritization of tasks. Maintains productivity standards. • Perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with physicians, CDI staff and coders. • Assumes responsibility for professional development through participation at workshops, conferences, and/or in-services and maintains appropriate records of participation. • Complies with and ensures adherence to HIPAA and Code of Conduct policies.

🎯 Requirements

• Bachelor’s degree in Nursing, Health Information Management, or related medical field required. • Graduate Foreign Medical degree will be considered. • Current RN, MD or RHIA required • CCDS or CDIP certification preferred; shall obtain CCDS or CDIP within 3 years from date of hire • Coding certification (CCS, CIC, or CPC) preferred • 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.

🏖️ Benefits

• medical • dental • tuition remission • more