Clinical Documentation Specialist 1 - Remote

Overview

The Clinical Documentation Integrity Specialist 1 (CDIS) at the University of Miami performs clinically based health record reviews to ensure accurate provider documentation for clinical conditions and procedures, supporting high-quality clinical documentation and compliance.

In Short

• Perform health record reviews for clinical documentation accuracy.
• Collaborate with healthcare team members to improve documentation.
• Ensure compliance with coding and regulatory standards.
• Utilize critical thinking to identify documentation improvement opportunities.
• Maintain productivity and quality standards in documentation.
• Communicate effectively with providers regarding documentation queries.
• Participate in professional development activities.
• Adhere to HIPAA and Code of Conduct policies.
• Work independently and manage time effectively.
• Document findings accurately in CDI software.

Requirements

• Bachelor’s degree in Nursing, Health Information Management, or related field.
• Current RN, MD, or RHIA required; CCDS or CDIP preferred.
• At least two years of direct patient care or three years of inpatient coding experience.
• Proficiency in ICD-10-CM/PCS and DRG assignment.
• Strong critical-thinking and communication skills.
• Experience with Microsoft Office and healthcare software.
• Ability to work collaboratively in a team environment.
• Willingness to learn and accept constructive feedback.
• Maintain compliance with quality and query standards.
• Experience with clinical documentation improvement preferred.

Benefits

• Competitive salary and comprehensive benefits package.
• Medical and dental insurance.
• Tuition remission for employees.
• Professional development opportunities.
• Supportive work environment promoting diversity and inclusion.
• Access to a vibrant academic and healthcare community.
• Participation in a leading-edge healthcare system.
• Recognition for excellence in teaching and research.
• Opportunities for career advancement.
• Commitment to employee well-being and safety.