CDI Specialist: Clinical Documentation & Education

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

Benefits offered by this job

Comprehensive benefits package

Equity stock purchase plan

401(k) contribution

Job summary

UnitedHealth Group is seeking a CDI Specialist with strong experience in inpatient clinical documentation improvement. The role focuses on reviewing acute care records, clarifying documentation with physicians, and leading educational initiatives to ensure accurate coding and improved patient care outcomes.

Responsibilities include regular communication with providers, collaboration with Care Coordination and HIM teams, and utilization of CDI technology to document clarification activity.

Qualifications

• Associate's degree required
• 5+ years acute care hospital clinical RN experience or CDI experience
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology
• Advanced level of proficiency communicating & working closely with Physicians
• Intermediate level proficiency with Windows PC apps (Word, Excel, PowerPoint) and EMR

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in documentation for accurate code assignment
• Conducts daily follow-up with providers to obtain documentation specificity
• Communicates with providers to clarify diagnoses based on severity of illness and risk of mortality
• Performs regular rounding with unit-based physicians and provides Working DRG lists
• Leads physician education strategies to improve clinical documentation
• Provides timely feedback to providers on documentation opportunities
• Ensures effective utilization of CDI technology and approved clarification forms
• Coordinates meetings with HIM Coding Professionals to reconsolidate DRGs and monitor queries
• Engages physician advisors and Care Coordination to resolve issues related to clarifications

Skills

RN clinical experience

CDI experience

Physician communication

Clinical pharmacology

Education

Associate's degree

BSN (preferred)

Tools

Electronic Medical Records

Microsoft Word

Microsoft Excel

PowerPoint

Job description

UnitedHealth Group is seeking a CDI Specialist with strong experience in inpatient clinical documentation improvement. The role focuses on reviewing acute care records, clarifying documentation with physicians, and leading educational initiatives to ensure accurate coding and improved patient care outcomes.

Responsibilities include regular communication with providers, collaboration with Care Coordination and HIM teams, and utilization of CDI technology to document clarification activity.