CDI Specialist II

CDI Specialist Position

Position Duties

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.

Minimum Required Qualifications

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.

Length of Assignment - 13 Weeks

Shift / Hours Per Week - X5 - 8hr shifts. 40 hrs per week. Start between 6am-8:30am off by 6:30pm (anywhere within this time frame work 8 hours within this time frame) Start Date - ASAP