Clinical Documentation Specialist II(Remote)

• Position Type: Fully Remote

• Temp-to-Perm: Possible

• Schedule: 40 hours/week

  • 5 days per week

  • 8-hour shifts

  • Start time between 6:00 AM and 8:30 AM

  • Must finish by 6:30 PM

  • Any 8-hour shift within this timeframe is acceptable

Required Qualifications

• Must hold CDIP or CCDS certification

• Minimum 3 years of inpatient adult bedside experience

• 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)
  
  Required Skills & Experience:
  -At least three (3) years of relevant CDI, clinical, coding, experience.
  -Medical graduates must have two (2) years or greater in clinical practice.
  -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

  Preferred Education:
  -N/A

  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.