CDI Specialist: Acute Care Documentation Improvement

Jobtome; Compton (CA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Benefits package

Equity stock purchase

401k contribution

Job summary

UnitedHealth Group's Optum team seeks a CDI-focused professional to review inpatient records within 24–48 hours of admission, identify documentation gaps, and drive accurate coding. You will work with physicians and care teams to clarify diagnoses based on severity and mortality risk, delivering targeted education on documentation improvement.

The role demands an RN with acute care experience or a medically trained CDI background, plus advanced knowledge of clinical medicine, pathophysiology,

Qualifications

• RN clinical background in acute care.
• Medical graduate with CDI experience acceptable.
• Strong knowledge of medicine, pathophysiology and pharmacology.
• Excellent communication with physicians.
• Comfort with Windows PC software and EMR systems.

Responsibilities

• Reviews inpatient clinical records within 24–48 hours of admission to guide accurate code assignment.
• Follows up with providers daily to clarify documentation specifics.
• Interacts with physicians at all levels to explain documentation requirements based on illness severity and mortality risk.
• Performs rounding with unit physicians and provides DRG lists to Care Coordination.
• Educates physicians on documentation improvement strategies and engages in ongoing CDI activities.
• Collaborates with HIM Coding Professionals and Physician Advisor to resolve issues and improve documentation.

Skills

RN experience

Interdisciplinary communication

Clinical medicine knowledge

Pathophysiology

Pharmacology

Education

Associate's degree

Tools

EMR

Microsoft Word

Microsoft Excel

PowerPoint

Job description

UnitedHealth Group's Optum team seeks a CDI-focused professional to review inpatient records within 24–48 hours of admission, identify documentation gaps, and drive accurate coding. You will work with physicians and care teams to clarify diagnoses based on severity and mortality risk, delivering targeted education on documentation improvement.

The role demands an RN with acute care experience or a medically trained CDI background, plus advanced knowledge of clinical medicine, pathophysiology,