Clinical Documentation Specialist

Position Title:

Clinical Documentation Specialist

Department:

Clinical Document Improvement

Job Description:

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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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.