Clinical Documentation Specialist II(Remote)

Collaborates proactively with Coding, Quality, Case Management, other interdisciplinary teams, and CDI leadership to resolve documentation and coding discrepancies. 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).

Required Qualifications

• Must hold CDIP or CCDS certification
• Minimum 3 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 the OUH-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:

-Independently conducts concurrent and/or retrospective reviews of inpatient medical records across
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.