Clinical Documentation Specialist

🕒 August 27

🌪️ Kansas, Oklahoma, +2 more states – Remote

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

⏰ Full Time

🟢 Junior

🏥📝 Medical Writer

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👻 Ghost score 44%

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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

• Conduct concurrent and/or retrospective reviews of inpatient medical records • Evaluate the accuracy, completeness, and specificity of provider documentation • Identify and act on documentation opportunities involving diagnoses, complications, comorbid conditions, procedures, CC/MCC capture, and POA indicators • Apply clinical knowledge to assess documentation consistency with the clinical picture • Initiate compliant, non-leading CDI queries • Monitor query status and follow escalation and retention processes • 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, regulatory, HIPAA, and privacy requirements • 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 • Complete CDI orientation and ongoing education • Develop proficiency in SOI/ROM, quality indicators, and risk adjustment • Evaluate documentation by medical staff and the healthcare team according to hospital CDI 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 • Associate’s degree required for Level 1 • Bachelor’s degree required for Levels 2 and 3 • At least 1 year of relevant clinical, coding, utilization review, or healthcare documentation experience for Level 1 • At least 3 years of relevant CDI, clinical, or coding experience for Level 2 • At least 5 years of progressive CDI, clinical, coding, or healthcare documentation experience for Level 3 • Active clinical or health information credential required, such as RN, LPN, Physician’s Assistant, Nurse Practitioner, RHIA, RHIT, CCS, or CPC • Medical graduates must have 2 or more years of clinical practice • Foreign medical graduates must have USMLE certification • CDI certification CCDS or CDIP required for Levels 2 and 3 • Foundational knowledge of clinical documentation improvement 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 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 • Ability to demonstrate developing competency in CDI review and query practices • Ability to follow compliant query standards and organizational policies • 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