CDI Specialist — Clinical Documentation & Physician Collaboration

Optum; Pico Rivera (CA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

Equity stock purchase

401k contribution

Job summary

Optum is seeking an experienced clinician to review inpatient records within 24–48 hours of admission and identify gaps in documentation for accurate coding. You will work closely with physicians to obtain necessary specificity and educate on documentation requirements to reflect illness severity and care intensity.

The role involves leading CDI initiatives, coordinating with HIM Coding Professionals, and using Optum CDI 3D tools to document clarifications.

Qualifications

• Associate's degree required with CDI/acute care experience.
• Advanced knowledge of clinical medicine and pharmacology.
• Strong communication with physicians and care teams.
• Experience with EMR and Windows software required.

Responsibilities

• Review inpatient records within 24–48 hours of admit to identify documentation gaps.
• Communicate with providers to obtain documentation specificity for accurate coding.
• Lead physician education strategies to improve clinical documentation.
• Coordinate with HIM Coding Professionals and CDI teams regularly.

Skills

RN experience

Clinical medicine

Physician communication

EMR proficiency

PC tools (MS Word/Excel/PP)

Education

Associate's degree

BSN degree (preferred)

Tools

EMR systems

Microsoft Word

Excel

PowerPoint

Job description

Optum is seeking an experienced clinician to review inpatient records within 24–48 hours of admission and identify gaps in documentation for accurate coding. You will work closely with physicians to obtain necessary specificity and educate on documentation requirements to reflect illness severity and care intensity.

The role involves leading CDI initiatives, coordinating with HIM Coding Professionals, and using Optum CDI 3D tools to document clarifications.