Non-Clinical - Clinical Documentation Specialist

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

Job summary

Cynet Health in Oklahoma City seeks a Clinical Documentation Specialist to independently review inpatient records, identify documentation gaps, and ensure accuracy of diagnoses and procedures. This contract role focuses on CDI workflows and collaboration with coding and quality teams.

You will craft compliant CDI queries, follow up on responses, mentor junior staff, and promote best practices across service lines. A minimum of 3 years inpatient CDI experience and active credentials are required.

Qualifications

• Working knowledge of CDI review and query practices
• Understanding of documentation accuracy requirements, quality measures, and risk adjustment principles
• Excellent verbal and written communication skills
• Strong ability to apply clinical knowledge to documentation review and clarification
• Ability to collaborate with interdisciplinary teams to resolve documentation discrepancies
• Adherence to regulatory and privacy standards

Responsibilities

• Independently conducts concurrent and/or retrospective reviews of inpatient medical records across assigned service lines.
• Identifies and acts on documentation gaps related to principal diagnosis, secondary diagnoses, complications, comorbidities, procedures, and clinical validation.
• Applies advanced clinical reasoning to assess consistency between clinical indicators and documented diagnoses.
• Prioritizes high impact cases based on acuity, quality indicators, and organizational focus.
• Independently formulates and issues compliant, non-leading CDI queries following established policies and nationally recognized query standards.
• Manages query follow up and escalation in alignment with established processes.
• Ensures queries are clinically sound, clearly written, and appropriately supported by documentation.
• Communicates effectively and professionally with providers to clarify documentation and promote best practices.
• Serves as a trusted documentation resource for providers within assigned service lines.
• Collaborates proactively with Coding, Quality, Case Management, and other interdisciplinary teams to resolve documentation and coding discrepancies.
• Identifies documentation opportunities impacting quality metrics and clinical validation.
• Adheres to regulatory and compliance requirements, including privacy standards.
• Serves as an informal mentor and resource to junior staff.
• Shares knowledge and best practices related to documentation standards and CDI workflows.
• Participates in ongoing CDI education and professional development activities.
• Performs other duties as assigned.

Skills

CDI knowledge

Documentation review

Communication skills

Clinical terminology

Job description

Non-Clinical - Clinical Documentation Specialist

Profession: Non-Clinical Specialists/Professionals

Specialty: Clinical Document Improvement

Duration: 13 weeks

Shift: Days

Hours per Shift: 8 hours

Experience: Minimum 3 years of inpatient adult experience; critical care and trauma experience preferred

License: Active clinical or health information credential required

Certifications: CDIP or CCDS required

Must-Have:

• Working knowledge of clinical documentation improvement (CDI) review and query practices
• Understanding of documentation accuracy requirements, quality measures, and risk adjustment principles
• Excellent verbal and written communication skills
• Strong ability to apply clinical knowledge to documentation review and clarification

Description:Independently conducts concurrent and/or retrospective reviews of inpatient medical records across assigned service lines.Identifies and acts on documentation gaps related to principal diagnosis, secondary diagnoses, complications, comorbidities, procedures, and clinical validation.Applies advanced clinical reasoning to assess consistency between clinical indicators and documented diagnoses.Prioritizes high impact cases based on acuity, quality indicators, and organizational focus.Independently formulates and issues compliant, non-leading CDI queries following established policies and nationally recognized query standards.Manages query follow up and escalation in alignment with established processes.Ensures queries are clinically sound, clearly written, and appropriately supported by documentation.Communicates effectively and professionally with providers to clarify documentation and promote best practices.Serves as a trusted documentation resource for providers within assigned service lines.Collaborates proactively with Coding, Quality, Case Management, and other interdisciplinary teams to resolve documentation and coding discrepancies.Identifies documentation opportunities impacting quality metrics and clinical validation.Adheres to regulatory and compliance requirements, including privacy standards.Serves as an informal mentor and resource to junior staff.Shares knowledge and best practices related to documentation standards and CDI workflows.Participates in ongoing CDI education and professional development activities.Performs other duties as assigned.