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 include a Bachelor’s Degree in a related field, RHIA or RHIT Certification, and a minimum of 2 years of relevant experience. The role requires general knowledge of office procedures and operations, ability to accurately prepare and maintain records, files, reports and correspondence, effective communication skills, skill in data entry with minimal errors, ability to handle difficult and stressful situations professionally, maintain effective interpersonal relationships, and 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 is South Florida's only university-based health system providing leading-edge patient care powered by groundbreaking research and medical education at the Miller School of Medicine. The University of Miami is an Equal Opportunity Employer encouraging females, minorities, protected veterans, and individuals with disabilities to apply.
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