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Clinical Document Improvement Specialist-HIM Dept. (Telecommute) )

HEALTH INFORMATION MGMT (MR) Florida-Miami-Waterford Offices Miami, Florida Requisition ID 19354


Job Summary

Ensure overall quality and completeness of clinical documentation. Facilitates clarification of clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to support appropriate reimbursement. Ensure clinical severity is captured for the level of service rendered to all patients with a DRG-based payer (Medicare, Medicaid, Champus). Responsible for timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates/trains all members of the patient care team on an ongoing basis.

Minimum Job Requirements

  • Associate in Science in Nursing or Health Information Management required.
  • Active membership in national association with required C.E. hours.
  • 2-3years of clinical documentation experience.
  • 2-3 years of work experience in Health Information Management department.


Essential Duties and Responsibilities

  • Conducts follow-up reviews of clinical documentation with physicians queried. Ensure points of education & clarification have been recorded in the patient’s chart and contacts physicians.
  • Coordinates with clinical staff and others responsible for clinical pertinence record reviews to ensure chart reviews are accurate, complete & submitted in a timely manner.
  • Ensures the existence of action plans if corrective steps are needed.
  • Educates and trains all internal clinical customers on clinical documentation opportunities, coding, and reimbursement issues to better reflect the patient care provided.
  • Serves as a member of TDI work group (clinicians, physicians, and coders) to enable the ongoing overall accuracy of clinical records. .
  • Ensures quality & completeness of documentation by performing in-house patient medical record documentation assessments by following certain selection criteria & clinical documentation guidelines.
  • Ensures completion of the Teaming for Documentation Integrity (TDI) worksheet for an initial processing and assessment of selected inpatient charts to determine if physician query is required.
  • Prepares monthly and quarterly reports on hospital-wide clinical pertinence data for submission to appropriate committees to enable the hospital to meet TJC standards on clinical documentation.
  • Queries physicians by means of the TDI Query form, when missing/additional clinical documentation/information is needed and follows up on all queries.
  • Responsible for record follow-up reviews in TDI database and submits report to Director/Manager on a weekly basis for analysis.
  • Reviews & assesses records from a coding perspective using the 3M encoder to ensure the capture of documentation elements that impact reimbursement accuracy & hospital case mix. .


  • Bachelor of Science in Nursing or Health Information Management preferred.
  • LPN/RN license to practice in the State of Florida preferred.
  • RHIA, RHIT, CDIP, CCS, and/or CPC-H preferred.
  • I-10 Certified experience preferred.
  • Ability to communicate effectively verbally and in writing.
  • Ability to prioritize work independently and evaluate workload in order to meet deadlines
  • Ability to relate cooperatively and constructively with customers and co-workers.
  • Ability to learn appropriate software application(s).
  • Able to maintain confidentiality of sensitive information.
  • Knowledge of DRG payer issues, documentation opportunities & clinical documentation requirements.
  • Proficient in Microsoft Word, Excel and PowerPoint.
  • Excellent observation, analytical thinking, and problem-solving skills.
  • Ability to interpret, adapts to, and reacts calmly under stressful conditions.


Job :


Primary Location :

Florida-Miami-Waterford Offices

Department :


Job Status

:Full Time

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