Job Description

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

Job Description & Requirements

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

*** Pay is based on years of applicable experience and acuity level of position

Position Title:

Department:

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.

OU Health Job ID #R0054678. Posted job title: Clinical Documentation Integrity (CDI) Specialist

About OU Health

OU Health is the state’s only comprehensive academic health system of hospitals, clinics and centers of excellence. With 11,000 employees and more than 1,300 physicians and advanced practice providers, OU Health is home to Oklahoma’s largest doctor network with a complete range of specialty care. OU Health serves Oklahoma and the region with the state’s only freestanding children’s hospital, the only National Cancer Institute-Designated OU Health Stephenson Cancer Center, Oklahoma’s flagship hospital, which serves as the state’s only Level 1 trauma center and Edmond Medical Center in the heart of the Edmond Community. Becker’s Hospital Review named University of Oklahoma Medical Center one of the 100 Great Hospitals in America for 2020. OU Health’s oncology program at OU Health Stephenson Cancer Center was named Oklahoma’s top facility for cancer care by U.S. News & World Report in its 2020-21 rankings. OU Health also was ranked by U.S. News & World Report as high performing in these specialties: Colon Surgery, COPD and Congestive Heart Failure. OU Health’s mission is to lead healthcare in patient care, education and research.

Experts in prevention, treatment and cures, our team works to improve lives through innovation in medical care, education and research, while investing in the people, technologies and facilities that will enable us to achieve our goals. We are seeking individuals who have a passion and talent for caring for others. By joining our team, you will provide quality health care to our community through the work you do every day. We provide clinical and non-clinical opportunities to further your career and we invite you to explore our available positions.

Benefits

• Medical benefits
• Dental benefits
• Vision benefits
• Life insurance
• Pet insurance
• Sick pay
• Continuing Education
• 401k retirement plan
• Wellness and fitness programs
• Employee assistance programs
• Benefits start day 1

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