CDI Specialist
On-siteMiami, Florida, United States
Job Summary
Review clinical documentation in patient records to identify gaps or inconsistencies and engage with healthcare providers to clarify and obtain additional information as needed. Ensure documentation supports accurate coding and billing processes by collaborating with coding and billing teams to facilitate proper claim submissions. Monitor and report on documentation improvement initiatives and compliance with regulatory standards while providing education and training to clinical staff on documentation best practices. Stay current with industry regulations, coding guidelines, and documentation standards. Requires a Bachelor's degree in Nursing or Health Information Management, CCDS credential, and 2+ years of experience in clinical documentation improvement.
Required Qualifications
- Bachelor's degree in Nursing, Health Information Management, or a related healthcare field
- Certified Clinical Documentation Specialist (CCDS) credential or equivalent certification
- Minimum of 2 years experience in clinical documentation improvement or health information management
- Strong knowledge of medical terminology, anatomy, and clinical procedures
- Familiarity with ICD-10-CM, CPT coding systems, and healthcare reimbursement methodologies
Desired Qualifications
- Experience working in a hospital or acute care setting
- Additional certifications such as Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT)
- Proficiency with electronic health record (EHR) systems and clinical documentation software
- Demonstrated ability to lead documentation improvement projects
- Excellent communication and interpersonal skills for effective collaboration with multidisciplinary teams
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