Clinical Documentation Specialist

Pride Health; Oklahoma; Remote; USD 79,000 - 84,000; Full time

Job summary

Pride Health is seeking a Clinical Documentation Specialist II for a local contract in Oklahoma City, OK. You will conduct concurrent and retrospective reviews, identify documentation gaps, and develop compliant, non-leading queries. Schedule is 8-hour shifts, 40 hours per week, with an early start window.

This fully remote role covers OK, KS, MO, TX, and AR, with a 13-week term and potential to convert. Requires CCDS/CDIP, active clinical licensure (RN/LPN/PA/NP or RHIA/RHIT/CCS/CPC), and 3+

Qualifications

• CCDS or CDIP certification required.
• Active clinical/health information credential such as RN, LPN, PA, NP, RHIA, RHIT, CCS, CPC, or equivalent.
• USMLE certification is required for foreign medical graduates.
• 3+ years of relevant CDI experience.
• Minimum 3 years of inpatient adult bedside clinical experience.
• Critical care and trauma experience preferred.
• Strong knowledge of CDI practices, compliant query standards, clinical validation, quality measures, and risk adjustment.

Responsibilities

• Conduct concurrent and retrospective inpatient medical record reviews.
• Identify documentation gaps involving diagnoses, complications, comorbidities, procedures, CC/MCC, POA, and clinical validation.
• Develop and issue compliant, non-leading CDI queries.
• Follow up and escalation queries according to established processes.
• Collaborate with physicians, Coding, Quality, Case Management, and CDI leadership.
• Identify opportunities affecting SOI/ROM, quality metrics, and risk adjustment.
• Support CDI education, documentation integrity, and compliance initiatives.
• Mentor and guide CDS Level I staff.

Skills

CDI Certification

Inpatient CDI

Clinical documentation

Communication skills

Education

RN/LPN/PA/NP or RHIA/RHIT/CCS/CPC

USMLE for foreign grads

Job description

Pride Health is hiring a Clinical Documentation Specialist II to support our client's healthcare facility in Oklahoma City, OK.

Schedule: 8 hr shifts. 40 hrs per week. Start between 6 am-8:30 am– off by 6:30 pm (anywhere within this time frame – work 8 hours within this time frame)

Location: Fully Remote (Oklahoma, Kansas, Missouri, Texas, and Arkansas)

Float / Coverage Area:

Job Type: Local contract

Contract Length: 13 weeks Contract (Temp-to-Perm possibility)

Pay Range: $57.00 to $61.00/hour*

Note: Must have a computer set up with Windows 11, dual monitors, and a webcam.

*Pay offered is based on experience, expertise, credentialing, and education.

Duties:

• Conduct concurrent and retrospective inpatient medical record reviews.
• Identify documentation gaps involving diagnoses, complications, comorbidities, procedures, CC/MCC, POA, and clinical validation.
• Develop and issue compliant, non-leading CDI queries.
• Follow up and escalation queries according to established processes.
• Collaborate with physicians, Coding, Quality, Case Management, and CDI leadership.
• Identify opportunities affecting SOI/ROM, quality metrics, and risk adjustment.
• Support CDI education, documentation integrity, and compliance initiatives.
• Mentor and guide CDS Level I staff.

Requirements:

• License(s):
• Certification(s):
• CCDS or CDIP certification required.
• Active clinical/health information credential such as RN, LPN, PA, NP, RHIA, RHIT, CCS, CPC, or equivalent.
• USMLE certification is required for foreign medical graduates.
• Years of experience:
• 3+ years of relevant CDI experience.
• Minimum 3 years of inpatient adult bedside clinical experience.
• Critical care and trauma experience preferred.
• Strong knowledge of CDI practices, compliant query standards, clinical validation, quality measures, and risk adjustment.
• Excellent written/verbal communication and clinical judgment.
• Ability to independently manage CDI workload and meet productivity/quality KPIs.

For workers in the United States, PrideGlobal and it's affiliates offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, pet insurance and employee discounts with preferred vendors.

PrideGlobal and it's affiliates are an equal opportunity employer. We do not discriminate on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

PrideGlobal and it's affiliates are a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.

Only applicable for San Francisco Candidates: Under the San Francisco Lactation in the Workplace Ordinance, we will provide written notice of lactation accommodation rights, and this notice will automatically be given upon hiring, or upon any inquiry about parental leave or lactation accommodation.

Only applicable for Kentucky positions: For this type of employment, state law requires a criminal record check as a condition of employment. This applies to direct care staff (Examples: RN, LPN, Nurse Aides, Therapists) referred to Kentucky nursing facilities, assisted living communities, or long‑term care facilities, in accordance with KRS 216.793.