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The Clinical Documentation Specialist 1 provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services.

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.

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.

MINIMUM QUALIFICATIONS

Education:

Bachelor’s Degree in related field.

Certification and Licensing:

RHIA or RHIT Certification.

Experience:

Minimum 2 years of relevant experience.

Knowledge, Skills and Attitudes:

General knowledge of office procedures and operations

Ability to accurately prepare and maintain records, files, reports and correspondence

Ability to communicate effectively in both oral and written form. Skill in data entry with minimal errors.

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.

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.

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