临床文档专员
Clinical Documentation Specialist
职位名称：
临床文档专家
部门：
临床文档改进
职位描述
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远程资格：候选人必须在入职第一天前居住并全职工作于AR、KS、MO、OK或TX州。
概述
在CDI领导的指导下，CDI专家I负责审查住院患者病历，以支持准确、完整和合规的临床文档。此职位专注于基础的CDI功能，包括识别文档缺口、制定合规查询，并与提供者和跨学科团队合作，确保病历反映患者的临床状况、疾病严重程度、死亡风险、质量结果和服务内容。
核心职责
本部分列出的职责是该职位的核心。无法履行这些职责（无论是否需要合理调整）可能导致被取消任职资格。
- 临床文档审查
- 进行住院病历的实时和/或回顾性审查，以评估提供者文档的准确性、完整性和具体性。
- 识别并采取措施改进与主要诊断、次要诊断、并发症、共病、手术、CC/MCC捕获和POA指标相关的文档。
- 应用基本的临床知识来评估文档与临床情况的一致性。
- 查询实践
- 根据OU Health政策和国家认可的查询标准，发起合规的非引导性CDI查询。
- 监控查询状态并遵循既定的升级和保留流程。
- 确保查询清晰、有临床依据且专业地传达。
- 协作与沟通
- 与提供者有效沟通，以支持文档澄清和改进。
- 与编码、质量、病例管理、其他跨学科团队和CDI领导合作，确保文档和编码一致。
- 在适当的情况下，将复杂或不明确的案例升级至高级CDI员工或领导。
- 质量与合规
- 遵守与文档完整性相关的组织政策、监管要求和合规标准。
- 保持患者隐私并遵守相关法规。
查看英文原文
Position Title:
Clinical Documentation SpecialistDepartment:
Clinical Document ImprovementJob Description:
Job Description
New to OU Health? Ask your recruiter about our competitive wages and total rewards package!
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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