Description

The Clinical Documentation Improvement Specialist supports accurate, complete, specific, and compliant clinical documentation across Health Services. This position reviews clinical documentation and related coding outcomes to identify opportunities for improvement in chart clarity, completeness, and consistency. The role works collaboratively with providers, coding and billing staff, operational leaders, and external vendors to strengthen documentation practices that support accurate code assignment, regulatory compliance, UDS reporting, risk adjustment, quality reporting, and revenue integrity.  This position serves as an internal resource for documentation improvement and provides education, feedback, and process support to promote documentation that accurately reflects the patient’s condition, services provided, medical decision-making, and care outcomes.

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Requirements

MINIMUM QUALIFICATIONS
The following minimum qualifications are REQUIRED for this position:

• Bachelor's degree from an accredited college or university in nursing, physiology, health information management or other related fields; AND
• 1 year of experience in clinical documentation improvement, medical coding, medical auditing, health information management, revenue cycle, quality review, or a closely related healthcare role required

An equivalent combination of education and experience may be accepted. Please note candidates must have at least 6 months of actual work experience to be considered as equivalent.

Special Requirements

• Medical Records Coding certification; Certification of Coding Education Program (CCEP) or Certified Professional Coder (CPC) or ability to obtain within 6 months.
• Clinical Documentation Improvement certification such as CCDS or CDIP preferred, or ability to obtain within 6 months.
• Hiring is contingent upon the successful completion of a background check.

The Ideal Candidate

• Minimum of two years of experience in clinical documentation improvement, medical coding, medical auditing, health information management, revenue cycle, quality review, or a closely related healthcare role required.
• Strong knowledge of CPT, HCPCS, ICD-10-CM, and documentation requirements in ambulatory care, community health center, and/or FQHC settings preferred.
• Experience reviewing medical records for documentation quality, coding support, compliance, and/or billing accuracy required.
• Knowledge of healthcare reimbursement, payer requirements, medical necessity, and the relationship between documentation, coding, quality reporting, and revenue integrity preferred.
• Knowledge of HIPAA privacy laws and confidentiality requirements related to protected health information.
• Experience using Microsoft Office suite and electronic health record/practice management systems such as OCHIN Epic or similar systems required.
• Strong analytical skills and ability to interpret complex clinical documentation and communicate findings clearly and respectfully.
• Ability to work collaboratively with providers, operational leaders, external vendors, and non-clinical staff.
• Strong written and verbal communication skills, including ability to provide education and feedback in an effective and supportive manner.

Please ensure you have provided a thorough and updated application as it pertains to the position for which you are applying. Your application materials will be used to determine salary based on a pay equity assessment.  For further information, please click on the link: Oregon Pay Equity Law