Impactful CDI Specialist — Clinical Documentation

Embedded Shishya; United States; Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

PTO

401(k)

Medical and dental plans

Job summary

OU Health seeks a Clinical Documentation Specialist I to review inpatient records, identify gaps, and formulate compliant queries. You will collaborate with providers and interdisciplinary teams to ensure documentation reflects patient illness severity and services rendered.

Entry-level CDI role requiring an associated degree and clinical/documentation experience; growth through orientation and ongoing CDI education is expected.

Qualifications

• Education: Associate’s degree required.
• Experience: 1 year in clinical, coding, utilization review, or healthcare documentation.
• Certifications: active clinical or health information credential.

Responsibilities

• Conduces concurrent/retrospective reviews of inpatient records for accuracy and completeness.
• Initiates compliant, non-leading CDI queries per OU Health policies.
• Communicates with providers to clarify documentation and improve quality.
• Ensures documentation aligns with regulations, HIPAA, and organizational policies.
• Records review activity and outcomes in EHR/CDI systems.
• Completes required CDI orientation and ongoing education.

Skills

CDI basics

Query standards

Productivity standards

KPIs awareness

Communication skills

CDI training application

Compliant queries

Time management

Competency development

Education

Associate’s degree

Bachelor’s degree

CDDS/CDIP

Clinical health info credential

USMLE for foreign grads

Job description

OU Health seeks a Clinical Documentation Specialist I to review inpatient records, identify gaps, and formulate compliant queries. You will collaborate with providers and interdisciplinary teams to ensure documentation reflects patient illness severity and services rendered.

Entry-level CDI role requiring an associated degree and clinical/documentation experience; growth through orientation and ongoing CDI education is expected.