Clinical Documentation Integrity & Utilization Review Nurse
Resume:
W*w*ABIODUN A. OGUNLEYE, BSN, RN, CDIP
Clinical Documentation Integrity Specialist Clinical Validation Specialist Utilization Review Nurse
️ ***********@*****.***
PROFESSIONAL SUMMARY
Certified Documentation Integrity Practitioner (CDIP) and Registered Nurse with 19 years of progressive clinical nursing experience spanning behavioral health, medical-surgical, pediatric emergency, infectious disease, and acute inpatient care. Successfully completed the online and clinical AHIMA Clinical Documentation Integrity Apprenticeship at UTHealth Houston, gaining hands-on experience in concurrent inpatient documentation review, physician query development, clinical validation, ICD-10-CM documentation, MS-DRG optimization, CC/MCC capture, Severity of Illness (SOI), Risk of Mortality (ROM), Present on Admission (POA), and Medicare documentation compliance.
Recognized for exceptional clinical judgment, analytical thinking, interdisciplinary collaboration, and documentation excellence. Extensive experience utilizing Epic electronic health records to improve documentation accuracy, support compliant coding, optimize reimbursement, strengthen quality metrics, and ensure regulatory compliance.
Prepared to transition into a full-time Clinical Documentation Integrity Specialist, Clinical Validation Specialist, Utilization Review Nurse, Revenue Integrity, Quality Documentation, or Remote CDI role supporting healthcare organizations including Optum, UnitedHealth Group, Guidehouse, Humana, Mayo Clinic, HCA Healthcare, Conifer Health Solutions, Ensemble Health Partners, and academic medical centers.
CLINICAL DOCUMENTATION EXPERTISE
Clinical Documentation Integrity (CDI) • Concurrent Chart Review • Clinical Validation • Physician Query Development • ICD-10-CM Documentation • ICD-10-PCS Documentation Awareness • MS-DRG Optimization • APR-DRG Awareness • CC/MCC Capture • Severity of Illness (SOI) • Risk of Mortality (ROM) • Present on Admission (POA) • Hospital-Acquired Conditions (HACs) • Patient Safety Indicators (PSIs) • Medicare Documentation Requirements • Medical Necessity • Documentation Compliance • CMS Regulations • Joint Commission Standards • Clinical Indicators • Documentation Audits • Documentation Improvement • Revenue Cycle • Coding Collaboration • Denial Prevention • Quality Metrics • Risk Adjustment Fundamentals • Documentation Education • Utilization Review Collaboration • Care Coordination • Regulatory Readiness
CORE COMPETENCIES
Clinical Documentation Integrity (CDI)
Clinical Validation
Concurrent Inpatient Chart Review
Physician Query Development
Documentation Improvement
Clinical Documentation Auditing
Medical Necessity Review
Medicare Documentation Compliance
Quality Improvement
Patient Safety
Epic Electronic Health Record (EHR)
Omnicell Medication Management
Interdisciplinary Collaboration
Root Cause Analysis
Utilization Review Support
HIPAA Compliance
Documentation Accuracy
Evidence-Based Practice
Leadership
Change Management
Problem Solving
Clinical Decision Making
Communication
Microsoft Office Suite
Microsoft Teams
Outlook
Adobe Acrobat
PROFESSIONAL EXPERIENCE
REGISTERED NURSE – INPATIENT PSYCHIATRY
State Psychiatric Hospital Houston, Texas
2023 – Present
Provide comprehensive nursing care for adults with acute and chronic behavioral health conditions while ensuring accurate, timely, and compliant clinical documentation.
Selected Achievements
Maintain highly accurate electronic documentation utilizing Epic while ensuring regulatory compliance and documentation integrity.
Collaborate with psychiatrists, advanced practice providers, pharmacists, therapists, social workers, case managers, and interdisciplinary teams to coordinate patient-centered care.
Ensure documentation accurately reflects diagnoses, treatment plans, response to therapy, medical necessity, and discharge readiness.
Promote documentation excellence supporting quality reporting, patient safety initiatives, reimbursement integrity, and accreditation readiness.
Participate in performance improvement, infection prevention, and quality initiatives.
Serve as a mentor and preceptor to newly hired nurses while reinforcing documentation standards and best practices.
Consistently recognized for professionalism, leadership, teamwork, and clinical excellence.
AHIMA CLINICAL DOCUMENTATION INTEGRITY APPRENTICESHIP
UTHealth Houston Houston, Texas
January 2026 – June 2026
Completed a structured six-month Clinical Documentation Integrity Apprenticeship under experienced CDI Specialists within an academic medical center.
Clinical Documentation Experience
Conducted concurrent inpatient chart reviews evaluating documentation completeness, specificity, accuracy, and clinical integrity.
Identified documentation opportunities involving principal diagnoses, secondary diagnoses, CC/MCC capture, MS-DRG assignment, SOI, ROM, POA indicators, and reimbursement optimization.
Applied AHIMA best practices and ICD-10-CM documentation principles during concurrent medical record reviews.
Assisted in developing compliant physician queries supported by clinical evidence.
Reviewed physician documentation for coding specificity and documentation compliance.
Collaborated with CDI specialists, physicians, coding professionals, utilization review nurses, quality departments, revenue cycle teams, and case managers.
Utilized Epic electronic health records while participating in documentation improvement initiatives.
Participated in education related to Medicare documentation requirements, clinical validation, quality measures, reimbursement methodologies, physician engagement, and regulatory compliance.
CHARGE NURSE / REGISTERED NURSE
Medical-Surgical • Pediatric Emergency • Infectious Disease • Acute Care
Multiple Acute Care Hospitals
2004 – 2023
Provided evidence-based nursing care across multiple specialties while maintaining documentation supporting clinical quality, reimbursement integrity, and patient safety.
Selected Achievements
Delivered comprehensive nursing care across medical-surgical, pediatric emergency, infectious disease, psychiatric, and acute care environments.
Functioned as Charge Nurse overseeing patient assignments, admissions, staffing coordination, and interdisciplinary communication.
Maintained complete, timely, and compliant electronic documentation supporting continuity of care.
Collaborated with physicians and multidisciplinary teams to improve patient outcomes.
Recognized subtle changes in patient condition, ensuring documentation reflected severity of illness, clinical indicators, and medical necessity.
Participated in quality improvement, infection prevention, regulatory compliance, and patient safety initiatives.
Mentored newly hired nurses and nursing students on documentation accuracy and professional practice.
PROFESSIONAL ACHIEVEMENTS
Certified Documentation Integrity Practitioner (CDIP)
Successfully completed the AHIMA Clinical Documentation Integrity Apprenticeship
Recipient, Nurse of the Year Recognition
Recipient, Best Nurse Recognition
Merit Performance Recognition Award
Recognized for excellence in leadership, documentation accuracy, interdisciplinary collaboration, and patient-centered care
CERTIFICATIONS
Certified Documentation Integrity Practitioner (CDIP), AHIMA (2026)
AHIMA Clinical Documentation Integrity Apprenticeship Certificate (2026)
Registered Nurse – Texas (Active)
Basic Life Support (BLS)
Advanced Cardiovascular Life Support (ACLS)
Crisis Prevention Institute (CPI)
EDUCATION
Bachelor of Science in Nursing (BSN)
Associate degree/Diploma in Nursing
AHIMA Clinical Documentation Integrity Apprenticeship
TECHNICAL PROFICIENCIES
Epic Electronic Health Record (EHR) • Omnicell Medication Management • Microsoft Office Suite • Microsoft Teams • Microsoft Outlook • Adobe Acrobat • Electronic Medical Records (EMR) • Clinical Documentation Review Systems • Virtual Collaboration Platforms
QUALITY, COMPLIANCE & REVENUE INTEGRITY
CMS Documentation Requirements • Joint Commission Standards • HIPAA Compliance • Clinical Documentation Integrity • Documentation Accuracy • Clinical Validation • Documentation Audits • Medical Necessity • Documentation Improvement • Revenue Cycle Collaboration • Coding Compliance • Denial Prevention • Regulatory Readiness • Utilization Review Collaboration • Physician Documentation Improvement • Quality Metrics • Patient Safety
LEADERSHIP & COLLABORATION
Physician Collaboration • Interdisciplinary Communication • Documentation Education • Clinical Coaching • Team Leadership • Staff Mentorship • Conflict Resolution • Process Improvement • Quality Improvement • Change Management • Evidence-Based Practice • Performance Improvement
TARGET POSITIONS
Clinical Documentation Integrity Specialist
Clinical Documentation Integrity Educator
Clinical Validation Specialist
Clinical Documentation Reviewer
Utilization Review Nurse
Revenue Integrity Specialist
Documentation Quality Specialist
Clinical Appeals Nurse
Documentation Improvement Consultant
Remote CDI Specialist
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