Registered Nurse (RN) - Clinical Document Improvement Specialist - $30-46 per hour

RemoteWorker US; Oklahoma City (OK); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Document Improvement Specialist (RN) to conduct reviews of medical records, ensuring accurate documentation and collaborating with healthcare teams. This full-time role offers comprehensive benefits and can be performed remotely in specified states.

Benefits

PTO

401(k)

Medical/Dental

Qualifications

• Five years of acute care hospital experience or equivalent coding experience.

Responsibilities

• Evaluate medical records daily, including physician notes and treatment plans.
• Communicate with physicians to clarify documentation issues.
• Ensure complete and accurate documentation in accordance with hospital policies.

Skills

Communication

Organization

Planning

Education

Associate’s degree

BS in Nursing

Job description

Registered Nurse (RN) - Clinical Document Improvement Specialist - $30-46 per hour

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Position Overview

OU Health is seeking a Registered Nurse (RN) Clinical Document Improvement Specialist for a nursing position in Oklahoma City, Oklahoma.

Job Details

• Specialty: Clinical Document Improvement Specialist
• Discipline: RN
• Start Date: ASAP
• Duration: Ongoing
• Employment Type: Staff

Position Title

Clinical Documentation Integrity (CDI) Specialist

Department

Clinical Document Improvement

Job Description

This position may be performed remotely within the following states: 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.

The Clinical Documentation Integrity (CDI) Specialist conducts concurrent reviews of medical records to ensure accurate and detailed documentation. Responsibilities include collaborating with physicians and healthcare teams to clarify and improve documentation, understanding clinical complexities, and supporting accurate severity and risk assessments.

Responsibilities

• Evaluate medical records daily, including physician notes, lab results, and treatment plans.
• Communicate with physicians to clarify documentation issues.
• Ensure complete and accurate documentation in accordance with hospital policies.
• Understand clinical factors like complications, co-morbidities, and their impact on coding and reimbursement.
• Gather and analyze documentation findings.

Qualifications

• Associate’s degree required; BS in Nursing or RN preferred.
• Five years of acute care hospital experience or equivalent coding experience.
• Licenses/certifications such as CCP, CCDS, or CDIP are preferred.

Skills

• Excellent communication skills.
• Proficiency in organization, planning, and computer use.
• Knowledge of healthcare policies, quality improvement, and payer regulations.

Additional Information

OU Health offers comprehensive benefits, including PTO, 401(k), medical/dental, and more. The role is full-time, mid-senior level, and remote within specified states.