Clinical Documentation Specialist

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🔥 0 minutes ago

🌪️ Kansas, Oklahoma, +2 more states – Remote

🌪️ Kansas – Remote 🌪️ Oklahoma – Remote 🏰 Missouri – Remote 🤠 Texas – Remote

⏰ Full Time

🟢 Junior

🏥📝 Medical Writer

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OU Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

OU Health is a comprehensive healthcare provider offering a wide range of medical services including pediatric care, cancer care, diabetes care, emergency care, and specialized services for adults and children. Located in Oklahoma, OU Health operates multiple facilities such as the Oklahoma Children's Hospital and the Stephenson Cancer Center. Known for its advanced scientific research and quality care, the organization prides itself on being recognized for excellence in areas like pediatric cardiology and heart surgery. As part of its commitment to medical excellence, OU Health also focuses on medical education and research, helping to train the next generation of healthcare professionals.

📋 Description

• Review inpatient medical records concurrently and/or retrospectively for accuracy, completeness, and specificity of provider documentation • Identify documentation improvement opportunities related to principal and secondary diagnoses, complications, comorbid conditions, procedures, CC/MCC capture, and POA indicators • Apply basic clinical knowledge to assess documentation consistency with the clinical picture • Initiate compliant, non-leading CDI queries according to OU Health policies and nationally recognized query standards • Monitor query status and follow escalation and retention processes • Ensure queries are clear, clinically supported, and professionally communicated • Communicate with providers to support documentation clarification and improvement • Collaborate with Coding, Quality, Case Management, interdisciplinary teams, and CDI leadership • Escalate complex or unclear cases to senior CDI staff or leadership • Adhere to organizational policies, regulatory requirements, and compliance standards • Maintain patient confidentiality and comply with HIPAA and OU Health privacy standards • Participate in quality monitoring, audits, and performance improvement activities • Record review activity, queries, and outcomes in the electronic health record and CDI software • Meet productivity, quality, and accuracy expectations for a Level I role • Complete CDI orientation and ongoing education • Develop knowledge of SOI/ROM, quality indicators, and risk adjustment • Increase proficiency and independence in CDI review • Evaluate day-to-day documentation by the Medical Staff and healthcare team according to hospital policies and procedures • Perform other duties as assigned

🎯 Requirements

• Candidates must reside and work full-time in Arkansas, Kansas, Missouri, Oklahoma, or Texas before their first day of employment • Level 1: Associate’s degree required • Level 1: At least 1 year of relevant clinical, coding, utilization review, or healthcare documentation experience • Level 1: Active clinical or health information credential required, such as RN, LPN, Physician’s Assistant, Nurse Practitioner, RHIA, RHIT, CCS, or CPC • Level 1 medical graduates: verifiable 2 years or greater in clinical practice • USMLE certification required for foreign medical graduates • Level 2: Bachelor’s degree required • Level 2: At least 3 years of relevant CDI, clinical, or coding experience • Level 2: CDI certification CCDS or CDIP required • Level 2: Active clinical or health information credential required, such as RN, LPN, Physician’s Assistant, Nurse Practitioner, RHIA, RHIT, CCS, CPC, or equivalent as defined by OU Health • Level 2 medical graduates: 2 years or greater in clinical practice • Level 3: Bachelor’s degree required • Level 3: At least 5 years of progressive CDI, clinical, coding, or healthcare documentation experience • Level 3: CDI certification CCDS or CDIP required • Level 3: Active clinical or health information credential required, such as RN, LPN, Physician’s Assistant, Nurse Practitioner, RHIA, RHIT, CCS, CPC, or equivalent as defined by OU Health • Level 3 medical graduates: 2 years or greater in clinical practice • Foundational knowledge of CDI review and query practices • Knowledge of compliant query standards and organizational CDI policies • Understanding of productivity, quality, and documentation accuracy expectations • Awareness of departmental KPIs and performance requirements • Excellent verbal and written communication skills • Ability to apply CDI education and feedback to daily practice • Ability to produce compliant CDI queries with increasing consistency and accuracy • Time-management and organizational skills • Ability to demonstrate developing competency in CDI review and query practices • Ability to follow compliant query standards and organizational policies • Ability to show progressive improvement in productivity, quality, and documentation accuracy • Ability to incorporate feedback and education into ongoing performance • Ability to meet established departmental KPIs

🏖️ Benefits

• Competitive wages and total rewards package • Paid time off (PTO) • 401(k) • Medical plans • Dental plans • Comprehensive benefits package