Clinical Documentation Improvement Specialist

Oklahoma City Indian Clinic • Oklahoma City, OK

1d • Onsite

About The Position

The Clinical Documentation Improvement Specialist (CDIS) reviews patient medical records to ensure documentation accurately reflects the specificity of current conditions and the patient’s health status. The role conducts concurrent and retrospective reviews and works to improve documentation of conditions, treatments, and care plans to support high-quality patient care. The CDIS also educates clinical and coding staff on appropriate documentation criteria.

The position is with Oklahoma City Indian Clinic (OKCIC), a nonprofit corporation providing culturally sensitive healthcare and related services to the American Indian population. OKCIC’s mission is to provide excellent healthcare to American Indians by putting people first, providing quality services, and maintaining integrity and professionalism. Applicants claiming Indian Preference must complete the full application and provide documentation verifying eligibility, such as a tribal enrollment card or Certificate of Degree of Indian Blood (CDIB).

Requirements

• Must align with OKCIC’s vision, mission, and core values.
• Must have an RHIT, RHIA, or RN license/certification.
• If an RN, must have 5 years of experience, including at least 3 years of clinical nursing experience.
• Must have 5 years of experience working with coding and reviewing documentation.
• Must have knowledge of Medicare, Medicaid, commercial insurance, and major coding systems.
• Must contribute to cohesive group relationships and use open communication to identify and resolve problems within and between departments.
• Must adjust to workload peaks and demonstrate flexibility and adaptability.
• Must be able to work independently, demonstrate self-motivation, and adapt to a changing healthcare landscape.
• Must have excellent communication and analytical-thinking skills and meticulous attention to detail.
• Must have organizational and computer skills and a comprehensive understanding of healthcare regulations.
• Must have working knowledge of quality-improvement theory and practice, including required reporting programs.
• Must stay informed about healthcare-reform changes and integrate them into process improvement.

Nice To Haves

• Associate’s degree or higher preferred.

Responsibilities

• Conduct daily evaluations of medical records, including physician and clinical documentation, laboratory results, and treatment plans.
• Engage with physicians and healthcare teams to clarify and improve medical record documentation.
• Use data analysis to focus reviews on specific payers, DRGs, and teams.
• Collect and analyze program-outcome data to improve documentation and review processes.
• Identify opportunities to improve documentation and promote accurate, complete records.
• Review medical records for provider visits to identify missing or incomplete documentation that should be clarified.
• Collaborate with providers, case managers, coders, and other healthcare team members to ensure records comprehensively reflect clinical treatment, decisions, diagnoses, and interventions.
• Provide or coordinate education on compliance, coding, and clinical documentation issues, including potentially rounding with the multidisciplinary healthcare team.
• Consult with coding professionals when additional information or documentation is needed to assign coded data.
• Work with HIM/coding professionals to review problematic cases and ensure accurate final coded data, in conjunction with the Billing Director, coding leads, and physician advisors.
• Develop provider-education strategies to promote complete and accurate documentation and address negative trends.
• Identify patterns, trends, variances, and opportunities to improve documentation-review processes.
• Assist in developing and reporting performance measures to medical staff and other departments, and prepare physician-specific data information.
• Build expertise in query development, presentation, and standards, including published query guidelines and compliance expectations.
• Conduct independent research on clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree