Clinical Documentation Specialist

General Description

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Responsibilities

• 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.
• 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 Level I 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.

Essential Job Duties

• Evaluates the day-to-day documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.

Minimum Requirements

• 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.

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.