Associate Clinical Documentation Improvement Specialist

UnitedHealth Group; California; On-site; USD 60,000 - 107,000; Full time

Job summary

UnitedHealth Group is seeking an Associate Clinical Documentation Improvement Specialist in Concord, CA. You will review inpatient records to ensure accurate coding and drive improvements in documentation quality.

Ideal candidates have an MD/MBBS or active US RN license, with 2+ years CDI experience or 5+ years RN in acute care. Certification within 1 year is encouraged; strong clinical knowledge is required.

Qualifications

• Must have medical degree or RN with US license.
• CCDS, CDIP, or CCS certification or willingness to obtain within 1 year.
• 5+ years acute care RN experience or 2+ years as a CDI in an acute hospital.
• Advanced knowledge in medicine, pathophysiology, and pharmacology.

Responsibilities

• Review inpatient records within 24–48 hours of admit.
• Identify documentation gaps for accurate code assignment.
• Daily follow-up with providers on clarifications.
• Lead overall improvement in clinical documentation.

Skills

Clinical documentation

Provider communication

Leadership

HIM collaboration

Education

MD or MBBS

RN license in US

Tools

CDI software

EHR systems

Job description

About This Role

The Associate Clinical Documentation Improvement Specialist will provide expert-level review of inpatient clinical records, ensuring accurate documentation that reflects the severity of conditions and acuity of care provided. This role is ideal for individuals with a strong clinical background and a passion for improving health outcomes.

Highlights

• Pay: $60,200 - $107,400/year
• Location: Concord, CA
• Schedule: Full Time, Day shift

What You'll Do

• Provide expert level review of inpatient clinical records within 24-48 hours of admit.
• Identify gaps in clinical documentation that need clarification for accurate code assignment.
• Conduct daily follow-up communication with providers regarding existing clarifications.
• Provide expert level leadership for overall improvement in clinical documentation.
• Actively communicate with providers to clarify information and documentation requirements.
• Provide timely feedback to providers regarding clinical documentation opportunities.
• Ensure effective utilization of CDI software to document all clarification activity.
• Proactively develop a reciprocal relationship with HIM Coding Professionals.
• Engage and consult with Physician Advisor/VPMA when needed to resolve provider issues.

Requirements

Education

• Must be one of the following to qualify:
  • A Medical Graduate (MD or MBBS), OR
  • Registered Nurse (RN) with an active, unrestricted RN License in the US

Experience

• 5+ years of acute care hospital experience for RN candidates.
• 2+ years of experience working as a Clinical Documentation Improvement Specialist in an acute care hospital setting.

Licenses & Certifications

• Current CCDS, CDIP, or CCS Certification OR willing/able to obtain within 1 year of hire.
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology.

About UnitedHealth Group

UnitedHealth Group is a leading healthcare provider committed to delivering exceptional patient care. They focus on improving health outcomes and providing comprehensive benefits and career development opportunities for their employees.