Clinical Documentation Specialist

oumedicine; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

oumedicine is seeking a Clinical Documentation Specialist I to review inpatient records for accuracy and completeness under CDI leadership. You will identify documentation gaps, formulate compliant queries, and collaborate with providers to reflect the patient’s clinical status, severity, and services rendered.

The role involves concurrent/retrospective reviews, ensuring compliance with CDI standards, and participating in quality improvement initiatives while maintaining patient confidentiality

Qualifications

• Associate's degree required for Level 1 CDI role.
• Bachelor's degree required for Level 2 CDI role.
• CDI certification or eligibility preferred at higher levels.

Responsibilities

• Review inpatient medical records for accuracy, completeness, and specificity.
• Identify documentation gaps and initiate compliant CDI queries.
• Collaborate with providers and interdisciplinary teams to align documentation with clinical picture.
• Monitor query status and follow escalation processes.
• Maintain HIPAA and privacy standards and record activities in EHR/CDI systems.
• Participate in quality monitoring, audits, and performance improvement activities.

Education

Associate's degree

Bachelor's degree

Bachelor's degree

Job description

Position Title

Clinical Documentation Specialist

Department

Clinical Document Improvement

Job Description

New to OU Health? Ask your recruiter about our competitive wages and total rewards package!

Remote Eligibility

Candidates must reside and work full-time in AR, KS, MO, OK, or TX before their first day of employment.

General Description

Under the direction of CDI leadership, the CDI Specialist I is responsible for reviewing inpatient medical records to support accurate, complete, and compliant clinical documentation. This role focuses on foundational CDI functions, including identification of documentation gaps, formulation of compliant queries, and collaboration with providers and interdisciplinary teams to ensure the medical record reflects the patient's clinical condition, severity of illness, risk of mortality, quality outcomes, and services rendered.

Essential Job Duties

• Conducts concurrent and/or retrospective reviews of inpatient medical records to evaluate the accuracy, completeness, and specificity of provider documentation.
• Identifies and acts on opportunities to improve documentation related to principal diagnosis, secondary diagnoses, complications, comorbid conditions, procedures, CC/MCC capture, and POA indicators.
• Applies basic clinical knowledge to assess documentation consistency with the clinical picture.
• Initiates compliant, non leading CDI queries in accordance with OU Health policies and nationally recognized query standards.
• Monitors query status and follows established escalation and retention processes.
• Ensures queries are clear, clinically supported, and professionally communicated.
• Communicates effectively with providers to support documentation clarification and improvement.
• Collaborates with Coding, Quality, Case Management, other interdisciplinary teams, and CDI leadership to ensure documentation and coding alignment.
• Escalates complex or unclear cases to senior CDI staff or leadership as appropriate.
• Adheres to organizational policies, regulatory requirements, and compliance standards related to documentation integrity.
• Maintains patient confidentiality and complies with HIPAA and OU Health privacy standards.
• Participates in internal quality monitoring, audits, and performance improvement activities.
• Accurately records review activity, queries, and outcomes in the electronic health record and CDI software.
• Meets established productivity, quality, and accuracy expectations appropriate for a LevelI role.
• Completes required CDI orientation and ongoing education successfully.
• Demonstrates continuous learning of CDI concepts, including SOI/ROM, quality indicators, and risk adjustment.
• Actively works toward increasing proficiency and independence in CDI review.
• Completes required CDI orientation and ongoing education successfully.
• Demonstrates continuous learning of CDI concepts, including SOI/ROM, quality indicators, and risk adjustment.
• Actively works toward increasing proficiency and independence in CDI review.
• Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures.
• Performs other duties as assigned.

Education & Development

• Completes required CDI orientation and ongoing education successfully.
• Demonstrates continuous learning of CDI concepts, including SOI/ROM, quality indicators, and risk adjustment.
• Actively works toward increasing proficiency and independence in CDI review.
• Completes required CDI orientation and ongoing education successfully.
• Demonstrates continuous learning of CDI concepts, including SOI/ROM, quality indicators, and risk adjustment.
• Actively works toward increasing proficiency and independence in CDI review.
• Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures.
• Performs other duties as assigned.

Minimum Requirements (Level 1)

• Education : Associate's degree required.
• Experience: At least 1 year of relevant clinical, coding, utilization review, or healthcare documentation experience.
• Certification/License/Registration: Active clinical or health information credential required (e.g., RN, LPN, Physician's Assistant, Nurse Practitioner, RHIA, RHIT, CCS, CPC.) Medical graduates must have verifiable 2 years or greater in clinical practice. USMLE certification required for foreign medical graduates.

Minimum Requirements (Level 2)

• Education: Bachelors degree required.
• Experience: At least 3 years of relevant CDI, clinical, coding, experience.
• Certification/License/Registration: CDI certification CCDS or CDIP required. Active clinical or health information credential (e.g., RN, LPN, Physician's Assistant, Nurse Practitioner, RHIA, RHIT, CCS, CPC, or equivalent as defined by OU Health). Medical graduates must have 2 years or greater in clinical practice. USMLE certification is required for foreign medical graduates.

Minimum Requirements (Level 3)

• Education: Bachelor's degree required.
• Experience: At least 5 years of progressive CDI, clinical, coding, or healthcare documentation experience.
• Certification/License/Registration: CDI certification CCDS or CDIP Required. Active clinical or health information credential (e.g., RN, LPN, Physician's Assis