Clinical Documentation Integrity Specialist

Jobtailor; Oklahoma City (OK); On-site; USD 60,000 - 90,000; Full time

Job summary

Jobtailor is seeking a Clinical Documentation Improvement (CDI) specialist in Oklahoma City to review clinical documentation for accuracy and alignment with coding rules and regulatory standards.

You will identify documentation gaps, initiate clarifying queries, and collaborate with providers, coders, and care teams to ensure clean data and compliant coding. This role emphasizes productivity, quality, and staying current with regulatory updates in a fast-paced healthcare environment.

Qualifications

• 2 years of nursing or clinical coding experience.
• High School Diploma or GED.
• One of: AHIMA-RHIA, AHIMA-RHIT, AHIMA-CCS, AAPC-CIC, or RN.
• Experience reviewing clinical documentation for coding alignment preferred.
• Knowledge of clinical conditions, documentation standards, and coding principles.
• Ability to review clinical documentation, identify coding and data-integrity gaps, initiate clarification queries, and maintain productivity and accuracy.
• Equal opportunity employer; applicants considered regardless of protected status.

Responsibilities

• Review clinical documentation for accuracy, completeness, and alignment with coding and regulatory requirements
• Review medical records to identify gaps affecting coding accuracy and data integrity
• Initiate queries to obtain clarification and ensure complete, accurate documentation
• Apply clinical, documentation, and coding knowledge to medical records
• Maintain productivity and quality standards while managing assigned work queues
• Work with providers, coders, and care teams to support accurate documentation
• Communicate documentation needs and query requests clearly
• Identify documentation gaps and elevate appropriately
• Complete documentation reviews and queries promptly while maintaining quality
• Follow CDI workflows and support consistent documentation practices
• Support accurate documentation for appropriate coding and reimbursement
• Adapt to updates in documentation and regulatory requirements

Skills

Clinical Coding

Documentation Standards

Data Integrity Analysis

Query Initiation

Productivity Management

Education

Registered Nurse (RN)

AHIMA-RHIA

AHIMA-RHIT

AHIMA-CCS

AAPC-CIC

Job description

• Review clinical documentation for accuracy, completeness, and alignment with coding and regulatory requirements
• Review medical records to identify gaps affecting coding accuracy and data integrity
• Initiate queries to obtain clarification and ensure complete, accurate documentation
• Apply clinical, documentation, and coding knowledge to medical records
• Maintain productivity and quality standards while managing assigned work queues
• Work with providers, coders, and care teams to support accurate documentation
• Communicate documentation needs and query requests clearly
• Identify documentation gaps and elevate appropriately
• Complete documentation reviews and queries promptly while maintaining quality
• Follow CDI workflows and support consistent documentation practices
• Support accurate documentation for appropriate coding and reimbursement
• Adapt to updates in documentation and regulatory requirements

Requirements

• 2 years of nursing or clinical coding experience
• High School Diploma or GED
• One of: AHIMA-RHIA, AHIMA-RHIT, AHIMA-CCS, AAPC-CIC, or RN
• Experience reviewing clinical documentation for coding alignment preferred
• Knowledge of clinical conditions, documentation standards, and coding principles
• Ability to review clinical documentation, identify coding and data-integrity gaps, initiate clarification queries, and maintain productivity and accuracy
• Equal opportunity employer; applicants considered regardless of protected status

Core Competencies

Demonstrates expertise in clinical documentation review, ensuring accuracy and compliance with coding and regulatory standards. Proficient in identifying documentation gaps and initiating queries to support optimal coding and reimbursement processes.

Highest-signal resume keywords

• Clinical Documentation Review
• Coding Principles
• Regulatory Requirements
• AHIMA-RHIA Certification
• Nursing Experience

Hard Skills

• Clinical Coding
• Documentation Standards
• Data Integrity Analysis
• Query Initiation
• Productivity Management

Soft Skills

• Clear Communication
• Collaboration with Care Teams
• Problem-Solving

Certifications & Qualifications

• AHIMA-RHIA
• AHIMA-RHIT
• AHIMA-CCS
• AAPC-CIC
• Registered Nurse (RN)

Industry Keywords

• Clinical Documentation Improvement
• Coding Alignment
• Documentation Gaps
• Quality Standards
• Healthcare Compliance