Clinical Documentation Specialist 2

If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position using the Career worklet, please review this tip sheet.

The Clinical Documentation Specialist II (CDI) provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. The CDI II 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 patient severity 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.

• Facilitates appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality.
• Reviews medical records and identifies potential gaps in clinical documentation for all assigned patient types and payer populations as directed on admission and throughout the hospitalization.
• Performs initial, concurrent review and follow up on assigned population consistent with department volume and frequency requirements.
• Assigns working DRG based upon identification and selection of principal diagnosis, complications, or co-morbid conditions and/or valid OR procedures, including capture of POA indicators.
• Ensures documented conditions, clarifications, and coded diagnoses are clinically supported.
• Documents reviews and other pertinent information in designated systems by established deadlines.
• Uses clinical judgement to determine when and/or if a query is necessary.
• Queries physicians within established timelines via approved query forms for conflicting, imprecise, incomplete, illegible, or inconsistent documentation by requesting and obtaining additional documentation within the health record when appropriate.
• Uses clinical judgement to determine appropriate and relevant clinical indicators and to discern appropriate reasonable diagnostic options when formulating non-standard queries.
• Interacts with Physicians to complete/resolve queries prior to patient discharge.
• Performs timely reconciliation of CDI-assigned DRG against final coded DRG.
• Escalates DRG mismatches as appropriate per established departmental protocols.
• Develops collaborative relationships to facilitate accomplishment of work goals.
• Possesses excellent interpersonal skills in building, negotiating, and maintaining crucial relationships.
• Demonstrates a willingness and ability to assist others.
• Understands and supports documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx's.
• Recognizes opportunities for documentation improvement using strong clinical skills/knowledge.
• Uses critical thinking and sound judgment in decision making for reimbursement considerations in balance with regulatory compliance.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including house staff, attending physicians, allied health practitioners, nursing, and care management.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.
• Communicates with HIM staff and collaborates with them to resolve discrepancies with DRG assignments and other coding issues.
• Complete well-timed follow-up case reviews (and secondary reviews as needed) on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
• Participate in meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified.
• Other duties as may be assigned.
• 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.
• Adheres to University and unit-level policies and procedures and safeguards University assets.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

Education:
Bachelor's degree in health information management, Medicine or Nursing required. FMG will be considered.

Certification and Licensing:
CCDS certification preferred; Active BLS certification.

Experience:
3-5 yrs. experience required. Experience in Inpatient Coding/HIM, Case Management, Quality Review and/or other related clinical experience in an acute care facility preferred.

Knowledge, Skills and Attitudes:

• General knowledge of office procedures and operations
• Skill in data entry with minimal errors
• Ability to accurately prepare and maintain records, files, reports and correspondence
• Ability to communicate effectively in both oral and written form.
• Ability to handle difficult and stressful situations with professional composure.
• Ability to maintain effective interpersonal relationships.
• Ability to understand and follow instructions.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

Patient safety is a top priority. As a result, during the Influenza ("the flu") season (September through April), the University Of Miami Miller School Of Medicine requires all employees who provide ongoing services to patients, work in a location (all Hospitals and clinics) where patient care is provided, or work in patient care or clinical care areas, to have an annual influenza vaccination. Failure to meet this requirement will result in rescinding or termination of employment.

The University of Miami is an Equal Opportunity Employer - Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Click here for additional information.

Job Status:

Employee Type:

Pay Grade: