Clinical Documentation Specialist I

About the role

The Clinical Documentation Specialist I provides concurrent and retrospective review of inpatient medical records to ensure accurate documentation of severity of illness, risk of mortality, and appropriate reimbursement for acute care services at the University of Miami Health System.

Key responsibilities

• Review inpatient records, identify gaps, and assign working DRG based on diagnoses and procedures.
• Query physicians for clarification or missing information within established timelines.
• Collaborate with physicians, HIM staff, and nursing to improve documentation quality.
• Document reviews and queries in designated systems and reconcile CDI‑assigned DRG with final coded DRG.
• Participate in team meetings, education sessions, and data collection on report timeliness.

Required profile

• Bachelor’s degree in Nursing, Health Information Management, or related field (RN, MD, or RHIA required).
• At least two years of direct acute‑care patient experience or three years of inpatient coding experience.
• CCDS or CDIP certification preferred (to be obtained within three years).
• Strong clinical knowledge of disease processes, anatomy, and pathophysiology.

Required skills

• Proficiency with Microsoft Office suite (Excel, PowerPoint, Word, Outlook).
• Experience using 3M 360 Encompass or similar clinical documentation software.

What we offer

• Competitive salary and comprehensive benefits package including medical, dental, and tuition remission.
• Opportunity to work in a leading academic health system serving South Florida, Latin America, and the Caribbean.