Clinical Documentation Integrity (CDI) Specialist

OU Medicine; Oklahoma City (OK); Remote; USD 65,000 - 85,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Documentation Integrity (CDI) Specialist to enhance the quality of clinical documentation. This role involves daily evaluations of medical records, communication with healthcare teams, and ensuring compliance with documentation policies. The ideal candidate will have extensive clinical expertise and a strong understanding of documentation processes, contributing to improved patient care and accurate reimbursement.

Benefits

PTO

401(k)

Medical Plans

Dental Plans

Qualifications

• Five years acute care hospital experience required.
• Licensed healthcare experience or completion of medical school preferred.

Responsibilities

• Conducts concurrent review of clinical documentation.
• Communicates with physicians regarding documentation issues.
• Gathers and analyzes information pertinent to documentation findings.

Skills

Communication

Organization

Adaptability

Education

Associate’s degree

BS in Nursing

Tools

Database Analysis

Spreadsheet Analysis

Presentation Programs

Word Processing

Job description

Position Title: Clinical Documentation Integrity (CDI) Specialist Department: Clinical Document Improvement Job Description:

This position may be performed remotely from the following locations within the United States of America: Arkansas, Colorado, Florida, Georgia, Indiana, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and Wisconsin.

General Description: The Clinical Documentation Integrity (CDI) Specialist conducts concurrent review of the clinical documentation in the medical record to achieve more accurate and detailed documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient which will in turn improve the quality of patient care, more accurately portray the facility's quality outcomes ratings, reduce compliance risks, and capture appropriate reimbursement.

Essential Responsibilities:

• Provides daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans.
• Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.
• Communicates with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.
• Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.
• Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
• Gathers and analyzes information pertinent to documentation findings and outcomes.

General Responsibilities:

• Performs other duties as assigned

Minimum Qualifications:

Education: Associate’s degree required, BS in Nursing or Registered Nurse preferred.

Experience: Five years acute care hospital experience or RHIA/RHIT/CCS with five years acute care inpatient coding experience required. Licensed healthcare experience (RN, LPN, CRT/RRT) or completion of medical school preferred. Advanced clinical expertise and/or extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting preferred.

License(s)/Certification(s)/Registration(s) Required: CCP, CCDS or CDIP preferred.

Knowledge, Skills and Abilities:

• Excellent verbal and written communication skills;
• Proficiency in organization and planning;
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching;
• Understanding of organizational policies and procedures;
• Working knowledge of quality improvement theory and practice;
• Ability and willingness to seek out and accept change;
• Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice;
• Knowledge of federal, state and private payer regulations

Current OU Health Employees - Please click HERE to login. OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.