Advanced Practice Quality and Safety - Clinical Documentation Integrity

The Ohio State University

1d • Onsite

About The Position

The Advanced Practice Safety & Quality Clinical Documentation Integrity (CDI) APP plays a critical role in strengthening the accuracy, clarity, and completeness of the clinical record. This position directly supports organizational priorities in quality outcomes, patient safety, financial stewardship, regulatory compliance, and national ranking performance by ensuring that documentation accurately represents each patient's true clinical picture. High‑quality documentation is essential for reflecting actual patient acuity, capturing comorbid conditions, describing clinical complexity, and demonstrating the intensity of services delivered. These elements drive correct risk adjustment, which influences how patient outcomes are interpreted in publicly reported programs and national benchmarking platforms. Precise documentation contributes to the reliability of key performance metrics, including mortality index, complication rates, length‑of‑stay efficiency, readmission calculations, and CMS quality programs, so the care provided is evaluated fairly and transparently. By applying advanced clinical knowledge, critical thinking, and real‑time insight into patient care, the APP in this role ensures that documentation aligns with clinical reality. This includes recognizing missing or unclear elements in provider notes, identifying clinical indicators that support diagnoses, ensuring treatment plans are documented in a way that reflects decision‑making, and validating that severity‑of‑illness and resource utilization are fully captured. This APP also helps prevent documentation gaps that can affect coding accuracy, billing compliance, audit risk, and institutional financial performance. The role strengthens the integrity of the medical record by ensuring that documentation: Clearly describes differential diagnosis and diagnostic reasoning Accurately captures evolving acuity, organ dysfunction, and clinical complexity Reflects complications, comorbidities, and risk factors supported by clinical evidence Documents the rationale behind testing, monitoring, and therapeutic intensity Aligns with coding guidelines and supports complete, accurate code assignment Through consistent involvement in documentation review processes and collaboration with clinicians, coding professionals, quality teams, and CDI specialists, this APP helps ensure that the medical record serves as an accurate and reliable representation of the patient’s condition and the care delivered. This level of documentation integrity is foundational to benchmarking, reliable outcome reporting, high‑quality patient care, and the enterprise’s overall quality and safety performance.

Requirements

• Licensed Advanced Practice Registered Nurse (APRN) in the State of Ohio with national certification as an advanced practice provider with a minimum of a master’s degree with preference for doctoral degree OR Physician Assistant- Certified with a minimum of a Master of Physician Assistant Science and license as a Physician Assistant in the State of Ohio.
• Obtain and maintain hospital credentials to practice at the medical centers.
• Master's of Science Degree in Nursing with APRN Certification or Master's with PA-C or Master's in Nursing with APRN-CNS (Clinical Nurse Specialist) Certification required.
• 0 years of relevant experience required.

Nice To Haves

• At least two years of APP experience with proven experience in healthcare quality improvement, patient safety initiatives, and/or formal or informal clinical leadership roles preferred.
• 0-2 years of relevant experience preferred.
• Preference for doctoral degree.

Responsibilities

• Improving the accuracy, clarity, and completeness of clinical documentation to support organizational priorities in quality, safety, financial stewardship, and national ranking performance.
• Ensuring appropriate reflection of patient acuity, correct risk adjustment, and reliable performance in key quality metrics such as mortality, complications, length of stay efficiency, and CMS reporting programs.
• Applying advanced clinical knowledge and real‑time care insight to help ensure the medical record captures true clinical complexity and resource utilization.
• Recognizing missing or unclear elements in provider notes.
• Identifying clinical indicators that support diagnoses.
• Ensuring treatment plans are documented in a way that reflects decision‑making.
• Validating that severity‑of‑illness and resource utilization are fully captured.
• Preventing documentation gaps that can affect coding accuracy, billing compliance, audit risk, and institutional financial performance.
• Ensuring documentation clearly describes differential diagnosis and diagnostic reasoning.
• Ensuring documentation accurately captures evolving acuity, organ dysfunction, and clinical complexity.
• Ensuring documentation reflects complications, comorbidities, and risk factors supported by clinical evidence.
• Ensuring documentation documents the rationale behind testing, monitoring, and therapeutic intensity.
• Ensuring documentation aligns with coding guidelines and supports complete, accurate code assignment.
• Consistent involvement in documentation review processes and collaboration with clinicians, coding professionals, quality teams, and CDI specialists.

Benefits

• Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost.
• Paid time off, including sick and vacation time and 11 holidays.
• State retirement plan or an alternative retirement plan, both with generous employer contributions.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees