Position Title:

Department:

Job Description:

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**These positions are available in levels 2,or 3 depending on experience, education, and licenses/certifications**

***Ideal candidate will have bedside experience in Adult and/or ICU/Trauma areas of care. ***

Essential Job Duties

Responsibilities listed in this section are core to the position.  Inability to perform these responsibilities, with or without an accommodation, may result in disqualification from the position. 

• Clinical Documentation Review

  • 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.

• Query Practice

  • 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.

• Collaboration & Provider Engagement

  • 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.

• Quality, Compliance & Risk Adjustment

  • 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.

• Education & Mentorship

  • 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."

General Job Duties

• Performs other duties as assigned

Minimum Requirements (Level 2):

Education: Bachelors degree required.

Experience: At least 3 years of relevant CDI, clinical, coding, experience.

Certification/License/Registration: 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). Medical graduates must have 2 years or greater in clinical practice. USMLE certification is required for foreign medical graduates.

Minimum Requirements (Level 3):

Education: Bachelor’s degree required.

Experience: At least 5 years of progressive CDI, clinical, coding, or healthcare documentation experience.

Certification/License/Registration: 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). Medical graduates with 2 years or greater in clinical practice. USMLE certification required for foreign medical graduates.

Knowledge, Skills & Abilities

• 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

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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.