Clinical Documentation Excellence Lead

Oklahoma City Indian Clinic; Oklahoma City (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

Oklahoma City Indian Clinic is seeking a Clinical Documentation Improvement Specialist (CDIS) to review medical records and ensure documentation accurately reflects current conditions and health status. You will perform concurrent and retrospective reviews, educate staff on documentation criteria, and promote high-quality patient care.

The CDIS will collaborate with physicians, coders, and HIM staff to improve documentation, identify opportunities, and support compliant coding practices across

Qualifications

• Must align with OKCIC vision, mission and core values.
• Associate's Degree or higher preferred.
• Must have RHIT, RHIA, or RN license/certification; if RN, 5 years experience with at least 3 years in clinical nursing.
• Must have 5 years of experience working with Coding and reviewing documentation.
• Knowledge of Medicare, Medicaid, commercial insurance and major coding systems.
• Strong communication and analytical thinking, meticulous attention to detail.

Responsibilities

• Conduct daily evaluations of medical records, including physician and clinical documentation, lab results, and treatment plans.
• Engage with physicians to clarify and improve medical record documentation.
• Analyze data on payers, DRGs, and teams to improve documentation review processes.
• Identify opportunities to improve documentation and promote accuracy.
• Review records to clarify missing or incomplete documentation.
• Collaborate with providers, case managers, coders, and healthcare team members to ensure comprehensive documentation.
• Educate on compliance, coding and clinical documentation issues; may include rounding with the team.
• Consult with coding professionals to gather needed information for coded data.
• Review cases with HIM/coding to ensure accuracy of final data with Billing Director and physician advisors.
• Develop provider education strategies to promote complete documentation and correct negative trends.
• Identify patterns and trends to improve documentation review processes.
• Assist in developing and reporting performance measures to medical staff and departments.
• Enhance expertise in query development and standards.

Skills

Attention to detail

Analytical thinking

Excellent communication

Self-motivation

Adaptability

Independent work

Education

Associate's Degree or higher preferred

RHIT / RHIA / RN license

Job description

Oklahoma City Indian Clinic is seeking a Clinical Documentation Improvement Specialist (CDIS) to review medical records and ensure documentation accurately reflects current conditions and health status. You will perform concurrent and retrospective reviews, educate staff on documentation criteria, and promote high-quality patient care.

The CDIS will collaborate with physicians, coders, and HIM staff to improve documentation, identify opportunities, and support compliant coding practices across