INTEGRIS Health · 3 hours ago
Clin Documentation Specialist - Days
Oklahoma, United States
Full-time
Onsite
Mid, Senior Level
3+ years expINTEGRIS Health, Oklahoma’s largest not-for-profit health system, has a great opportunity for a Clinical Documentation Specialist in Oklahoma City, OK. This role involves evaluating the completeness and quality of clinical documentation while collaborating with healthcare professionals to ensure accurate medical records for quality reporting and MS-DRG assignment.
Health CareHealth DiagnosticsHospitalPersonal Health
Responsibilities
Performs concurrent review process for all selected admissions to facilitate comprehensive complete medical record documentation to accurately reflect the diagnoses, clinical treatment, and severity of illness of the patient
Demonstrates in-depth clinical knowledge of complex disease processes and procedures in an inpatient setting
Utilize current CMS, AHA, and AHIMA coding guidelines, conventions and coding clinics to accurately determine the principal and secondary diagnoses and procedures that affect the MS-DRG assignment
Demonstrates an understanding of complications/co-morbidities, secondary diagnosis, impact of procedures on MS-DRG assignment, as well as severity of illness, risk of mortality, case mix, inpatient quality reporting, and denial avoidance; with ability to impart this knowledge to physicians and other members of the healthcare team
Develops documentation query protocol and educates essential staff on processes
Initiates assertive and effective communication with physician or other care provider when documentation requires clarification is unclear, using the most appropriate communication method physician documentation request, face to face contact, phone call, etc
Tracks responses and trends compliance with documentation queries
Identifies trends in documentation and/or potential problems and develops action plans as needed
Works effectively with coding staff to clarify documentation issues on the back end
Provides information and education as necessary to physicians not responding to documentation requests
Identify patterns, trends, variances, and opportunities to improve documentation review processes
Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics
Contributes to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization
Reports to the System Manager of Clinical Documentation This position may have additional or varied physical demand and/or respiratory fit test requirements. Please consult the Physical Demands Project SharePoint site or contact Risk Management/Employee Health for additional information. Normal office conditions
All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status
Qualification
Required
RN with 3 years relevant experience, OR RHIT with 3 years relevant experience, OR RHIA with 3 years relevant experience, OR CCS with 3 years relevant experience
5 years of acute care hospital coding with a strong DRG background; or strong medical background with 5 years acute clinical experience
Benefits
Front loaded PTO
100% INTEGRIS Health paid short term disability
Increased retirement match
Paid family leave
Company
INTEGRIS Health
INTEGRIS Health is the state’s largest Oklahoma-owned health system and one of the state’s largest private employers, with hospitals, rehabilitation centers, physician clinics, mental health facilities, fitness centers, independent living centers, home health agencies and urgent cares throughout much of the state.
10001+ employees
H1B Sponsorship
INTEGRIS Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (37)
2024 (17)
2023 (12)
2022 (18)
2021 (15)
2020 (14)
Funding
Current Stage
Late StageLeadership Team
Timothy Pehrson
President and CEO
Thomas McQuillan
Chief Technology Officer
Recent News
2025-09-30
2025-06-17
2025-06-16
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