Clinical Documentation Improvement Specialist

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

Job Details

Job Location: CrossRock - Oklahoma City, OK 73134

Position Type: Full Time

Travel Percentage: Up to 10%

Job Shift: Day

Oklahoma City Indian Clinic (OKCIC) is a non-profit corporation that provides culturally sensitive health care to the American Indian population.

OKCIC services include not only basic medical care but also dental, optometry, behavioral health, fitness, nutrition, and other family programs.

Our mission is to provide excellent healthcare to American Indians. We do this by putting people first, providing quality services, and maintaining our Integrity and Professionalism.

We are looking to add compassionate team players to our growing team as we continue to work toward our goal of becoming the national model for American Indian Health Care.

The Clinical Documentation Improvement Specialist (CDIS) is responsible for reviewing a patient's medical record to ensure that the documentation accurately reflects the specificity of current conditions and accurately codes the patient's health status. Providing concurrent and retrospective reviews and improving documentation of all conditions, treatments, and care plans to ensure the highest quality of patient care. The CDIS will also educate clinical and coding staff on appropriate documentation criteria.

Applicants claiming Indian Preference must complete the full application and must provide documentation verifying eligibility (such as a tribal enrollment card or Certificate of Degree of Indian Blood (CDIB)).

Job duties include, but are not limited to:

• Conduct daily evaluations of medical records, including physician and clinical documentation, lab results, and treatment plans.
• Engage with physicians and healthcare teams to clarify and improve medical record documentation.
• Based on data analysis, focus on specific payers, DRGs, and teams. Collect and analyze data on program outcomes to improve documentation review and process.
• Identify opportunities to improve documentation and promote accurate, complete documentation.
• Review medical records for provider visits to identify opportunities to clarify missing or incomplete documentation.
• Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
• Provide or coordinate education related to compliance, coding, and clinical documentation issues within the healthcare organization. This may include rounding with the multidisciplinary healthcare team.
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure the accuracy of final coded data in conjunction with the Billing Director, coding leads, and physician advisors.
• Develop provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Identify patterns, trends, variances, and opportunities to improve documentation review processes.
• Assisted in developing and reporting performance measures to the medical staff and other departments and prepared physician-specific data information.
• Enhance expertise in query development, presentation, and standards (including understanding published query guidelines and practice expectations for compliance).
• Conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.

The Oklahoma City Indian Clinic is a non-profit organization and not a federal employer. Indian preference hiring laws apply. The Clinic is a 501(c)(3) non-profit corporation and an Equal Employment Opportunity (EEO) employer. The Clinic adheres to all applicable laws prohibiting discrimination in employment, including protections based on race, color, sex, national origin, age, disability, religion, veteran status, and other characteristics as required by federal, state, or local law.

Qualifications

• Must align with OKCIC vision, mission, and core values.
• Associate's Degree or higher preferred.
• Must have either: RHIT, RHIA, or RN license/certification. If RN, must have 5 years of experience, with at least 3 years of clinical nursing experience.
• Must have 5 years of experience working with Coding and reviewing documentation.
• Required knowledge of Medicare, Medicaid, commercial insurance and major coding systems.
• Contributes to cohesive group relationships; uses open communication to identify and resolve problems in and between departments.
• Adjusts to peaks in workload; demonstrates flexibility and adaptability.
• Able to work independently, demonstrating self-motivation, and adapting to the constantly changing healthcare landscape.
• Excellent communication, analytical thinking, and meticulous attention to detail.
• Proficient in organizational and computer skills, along with a comprehensive understanding of healthcare regulations.
• Working knowledge of quality improvement theory and practice, including required reporting programs.
• Must stay up to date and informed about changes in healthcare reform and integrate them into process improvement