Clinical Documentation Integrity Specialist
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Job Description
CDI Specialist conducting clinical documentation review for OU Health. Collaborating with physicians to improve patient care documentation accuracy and compliance.
Responsibilities:
- Conducts concurrent review of the clinical documentation in the medical record
- Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures
- 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
- Communicates with physicians regarding missing, unclear or conflicting medical record documentation
- Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
- Gathers and analyzes information pertinent to documentation findings and outcomes
Requirements:
- Associate’s degree required
- BS in Nursing or Registered Nurse preferred
- 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
- CCP, CCDS or CDIP preferred
- 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
Benefits:
- PTO
- 401(k)
- medical and dental plans
- comprehensive benefits package
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