OPT Clinical Documentation Specialist Jobs
Clinical Documentation Specialist jobs are well-suited for F-1 OPT students with backgrounds in health information management, nursing, or a related clinical field. Most roles qualify as specialty occupations, making them straightforward to justify for OPT authorization. STEM OPT extension is not available for this title, so a 12-month timeline applies.
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Job Summary
Reviews medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service, and hospital quality metrics. Reviews medical records, submits provider queries, and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy, quality, and completeness of provider documentation as well as accurate code assignment. Serves as second level reviewer, education resource, and preceptor. Participates in education to providers, CDI/Coding teams, and other departments.
Essential Functions
- All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference.
- Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency, and accuracy of clinical documentation.
- Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
- Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
- Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
- Stays current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
- Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)
- Assigns a working DRG for health care team discharge planning and CDI use.
- Serves as preceptor, resource, and second level reviewer for appropriate clinical documentation and query justification.
- Provides point of care education for providers as relates to accurate capture of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
- Performs other duties as assigned.
Supervisory/Management Responsibilities
- This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
- Education - Bachelor's degree - Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or other healthcare related field.
- Experience - Four (4) years adult medical/surgical/critical care/ER/PACU nursing coding or related experience. Two (2) years clinical documentation improvement experience.
In Lieu Of
- In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP/CCDS/CDIP.
Required Certifications, Registrations, Licenses
- One of the following certifications: RHIA, RHIT, CCS, CIC or holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.
- CCDS/CDIP.
Knowledge, Skills and Abilities
- Computer skills
- Communication skills with the ability to interact with providers
- Knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred.
Work Shift
Day (United States of America)
Location
Corporate
Facility
7001 Corporate
Department
70017540 Clinical Documentation Integrity
Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.
Inspire health. Serve with compassion. Be the difference.
Job Summary
Reviews medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service, and hospital quality metrics. Reviews medical records, submits provider queries, and reconciles discharged records. Collaborates with Coding and other departments to facilitate the highest level of accuracy, quality, and completeness of provider documentation as well as accurate code assignment. Serves as second level reviewer, education resource, and preceptor. Participates in education to providers, CDI/Coding teams, and other departments.
Essential Functions
- All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference.
- Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency, and accuracy of clinical documentation.
- Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
- Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
- Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
- Stays current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
- Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)
- Assigns a working DRG for health care team discharge planning and CDI use.
- Serves as preceptor, resource, and second level reviewer for appropriate clinical documentation and query justification.
- Provides point of care education for providers as relates to accurate capture of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
- Performs other duties as assigned.
Supervisory/Management Responsibilities
- This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
- Education - Bachelor's degree - Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or other healthcare related field.
- Experience - Four (4) years adult medical/surgical/critical care/ER/PACU nursing coding or related experience. Two (2) years clinical documentation improvement experience.
In Lieu Of
- In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP/CCDS/CDIP.
Required Certifications, Registrations, Licenses
- One of the following certifications: RHIA, RHIT, CCS, CIC or holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.
- CCDS/CDIP.
Knowledge, Skills and Abilities
- Computer skills
- Communication skills with the ability to interact with providers
- Knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred.
Work Shift
Day (United States of America)
Location
Corporate
Facility
7001 Corporate
Department
70017540 Clinical Documentation Integrity
Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.
See all 30+ OPT Clinical Documentation Specialist Jobs
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Get Access To All JobsTips for Finding OPT Sponsorship as a Clinical Documentation Specialist
Target hospitals with dedicated CDI departments
Large health systems like academic medical centers and regional hospital networks employ full CDI teams, making them more likely to have established OPT onboarding processes. Smaller practices rarely have the infrastructure to support work authorization paperwork.
Emphasize your clinical coding credentials upfront
Credentials like CCS, CDIP, or CCDS signal to employers that you meet the specialty occupation threshold. List them prominently on your resume and reference them in cover letters to reduce hesitation around OPT authorization from hiring managers unfamiliar with the process.
Connect OPT timing to your start date availability
Be transparent about your OPT start date and authorization window early in conversations. Employers appreciate clarity, and framing your 12-month window as a defined trial period often reduces the perceived risk of hiring an international candidate.
Pursue AHIMA or ACDIS membership before applying
Active membership in professional associations signals commitment to the field and gives you access to employer directories and job postings. It also strengthens your specialty occupation case by demonstrating professional engagement beyond coursework or degree completion.
Frame your degree alignment clearly in applications
DSS officers and employers both need to see that your degree field connects to clinical documentation work. Degrees in health information management, nursing, or health sciences map most cleanly. If your degree is adjacent, include a one-line explanation of the connection.
Browse OPT-friendly CDI roles on Migrate Mate
Migrate Mate surfaces Clinical Documentation Specialist roles from employers open to OPT candidates. Filtering by job type saves time and ensures you are not spending applications on employers who have already ruled out international candidates at the screening stage.
Clinical Documentation Specialist OPT: Frequently Asked Questions
Does a Clinical Documentation Specialist role qualify as a specialty occupation for OPT?
Yes, in most cases. Clinical Documentation Specialist positions typically require a bachelor's degree or higher in health information management, nursing, or a related clinical field, which meets the specialty occupation standard DSS uses to authorize OPT for a given role. If your job offer references a general degree requirement without specifying a field, ask the employer to clarify the educational standard in your offer letter, as vague language can complicate your OPT authorization paperwork.
Is a Clinical Documentation Specialist job STEM-eligible for the 24-month OPT extension?
No. Clinical Documentation Specialist roles fall under health information management and clinical coding, which are not classified under STEM-designated CIP codes. F-1 students in this field work within the standard 12-month OPT period. If you are pursuing a STEM extension, you would need to transition to a role or employer situation that qualifies, which typically means a different job title and field.
What degree background do employers expect for CDI roles on OPT?
Most employers expect a degree in health information management, nursing, or a clinical health science. Some accept degrees in biology or pre-med if paired with a credential like CDIP or CCDS from AHIMA or ACDIS. Your degree field matters because it establishes the specialty occupation connection that makes OPT authorization appropriate for the role. A mismatch between your degree and the job description is one of the more common reasons DSS employment authorization requests get delayed.
How do I find Clinical Documentation Specialist employers who are open to OPT candidates?
Migrate Mate is the most direct way to find Clinical Documentation Specialist roles from employers who have indicated openness to OPT work authorization. Browsing general job boards means filtering manually through hundreds of postings with no visibility into sponsorship or OPT stance. Migrate Mate organizes listings specifically for international students, so you spend time on roles that are actually within reach rather than applying broadly and waiting to find out.
Can I switch employers mid-OPT if I take a Clinical Documentation Specialist role and want to move to a different hospital?
Yes, OPT is not tied to a specific employer, but there are reporting requirements you must follow. You need to update your SEVIS record through your DSS within 10 days of starting with a new employer. The new role must still be directly related to your degree field. If there is any gap between jobs, that time counts against your 90-day unemployment limit, so minimizing transitions and overlapping your search with your current role is advisable.