Job description
Position Title:
Clinical Documentation SpecialistDepartment:
Clinical Document ImprovementJob Description:
Job Description
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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
Responsibilities listed in this section are core to the position. Inability to perform these responsibilities, with or without an accommodation, may result in disqualification from the position.
Clinical Documentation Review
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.
Query Practice
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.
Collaboration & Communication
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.
Quality & Compliance
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.
Documentation & Reporting
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 Level I role.
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
General Job Duties
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 Assistant, Nurse Practitioner, RHIA, RHIT, CCS, CPC, or equivalent as defined by OU Health). Medical graduates with 2 years or greater in clinical practice. USMLE certification required for foreign medical graduates.
Knowledge, Skills & Abilities
Foundational knowledge of clinical documentation improvement (CDI) review and query practices
Knowledge of compliant query standards and organizational CDI policies
Understanding of departmental productivity, quality, and documentation accuracy expectations
Awareness of department Key Performance Indicators (KPIs) and performance requirements
Excellent verbal and written communication skills
Skill in applying CDI education and feedback to daily practice
Skill in producing compliant CDI queries with increasing consistency and accuracy
Time-management and organizational skills to support productivity and quality improvement
Able to demonstrate developing competency in CDI review and query practices
Able to consistently follow compliant query standards and organizational policies
Able to show progressive improvement in productivity, quality, and documentation accuracy
Able to effectively incorporate feedback and education into ongoing performance
Able to meet established departmental KPIs
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Originally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.