Clinical Documentation Specialist II(Remote)
- LPN
- RHIA
- RHIT
- Regulatory Compliance
- HIPAA
Required Qualifications
- Must holdCDIP or CCDS certification
- Minimum3 years of inpatient adult bedside experience
- At least three (3) years of relevant CDI, clinical, coding, experience.
- Medical graduates must have two (2) years or greater in clinical practice
- Critical care and trauma experience preferred
- Candidates must already have CDI experience
- Training is not intended to teach CDI fundamentals; training will focus on theOUH-specific way of performing CDI
Location Requirements
Candidates must reside in one of the following states:
- Oklahoma (OK)
- Kansas (KS)
- Missouri (MO)
- Texas (TX)
- Arkansas (AR)
Additional Required Skills & Experience:
-Working knowledge of clinical documentation improvement (CDI) review and query practices.
-Knowledge of compliant query standards and organizational CDI policies.
-Understanding of documentation accuracy requirements, quality measures, and risk adjustment principles.
-Knowledge of departmental Key Performance Indicators (KPIs) and productivity standards.
-Understanding of documentation integrity and compliance expectations.
-Excellent verbal and written communication skills.
-Skill in producing high-quality, compliant CDI queries *Strong ability to apply clinical knowledge to documentation review and clarification.
-Skill in managing CDI workload efficiently while maintaining quality standards.
-Ability to integrate feedback and education into daily CDI practice.
-Skill in contributing to quality improvement and documentation integrity initiatives.
-Mentoring and peer-support skills within a CDI team environment.
-Able to demonstrate developing to advanced competency in CDI review and query practices.
-Able to independently manage assigned CDI workload with minimal supervision.
-Able to consistently meet established departmental KPIs for productivity and quality.
-Able to demonstrate sound clinical judgment in complex documentation scenarios.
-Able to show continuous improvement in productivity, quality, and documentation accuracy.
-Able to actively contribute to organizational quality improvement, risk adjustment, and compliance outcomes.
-Able to serve as a reliable resource and informal mentor within the CDI team.
Required Education:
-Bachelors degree
Required Certifications & Licensure:
-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).
-USMLE certification is required for foreign medical graduates.
Job Responsibilities:
assigned service lines.
-Identifies and acts on documentation gaps related to principal diagnosis, secondary diagnoses,
complications, comorbidities, procedures, CC/MCC capture, POA status, and clinical validation.
-Applies advanced clinical reasoning to assess consistency between clinical indicators and documented
diagnoses.
-Prioritizes high impact cases based on acuity, quality indicators, and organizational focus.
-Independently formulates and issues compliant, non leading CDI queries in accordance with OU Health policies and nationally recognized query standards.
-Manages query follow up and escalation in alignment with established query retention and escalation processes.
-Ensures queries are clinically sound, clearly written, and appropriately supported by documentation.
-Communicates effectively and professionally with providers to clarify documentation and promote best practices.
-Serves as a trusted documentation resource for providers within assigned service lines.
-Collaborates proactively with Coding, Quality, Case Management, other interdisciplinary teams, and CDI leadership to resolve documentation and coding discrepancies.
-Identifies documentation opportunities impacting SOI/ROM, quality metrics, and clinical validation.
-Adheres to all regulatory, compliance, and confidentiality requirements, including HIPAA and OU Health privacy standards.
-Serves as an informal mentor and resource to CDS Level I staff.
-Shares knowledge and best practices related to documentation standards and CDI workflows.
-Participates in ongoing CDI education and professional development activities.
Performs other duties as assigned.
Clinical Documentation Specialist II(Remote) · MetaSense Inc