CDI Specialist - Drive Clinical Documentation Quality

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

Benefits offered by this job

Comprehensive benefits

401k contribution

Equity stock plan

Incentive programs

Job summary

Optum is seeking an experienced CDI specialist to review inpatient records within 24-48 hours of admission and drive documentation improvements across physicians and coding staff.

The role emphasizes frequent provider engagement, DRG reconciliation, and education to support accurate severity-of-illness coding using Optum CDI tools, with a strong focus on care coordination and quality initiatives.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital RN experience OR Medical Graduate with CDI experience.
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced level of proficiency communicating and working with physicians.
• Intermediate level of proficiency using a PC in Windows (Word, Excel, PowerPoint, EMR).

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit and identify documentation gaps for accurate code assignment.
• Follow up daily with providers to obtain documentation specificity.
• Clarify information and communicate documentation requirements for diagnoses based on severity and risk of mortality.
• Perform regular rounding with unit-based physicians and provide Working DRG lists to Care Coordination.
• Provide face-to-face education opportunities with physicians.
• Follow through on requests for clarification and recommendations for improvement.
• Lead the development and execution of physician education strategies for improved documentation.
• Provide timely feedback to providers on documentation opportunities and successes.
• Ensure effective use of Optum CDI 3D Technology to document clarification activity.
• Use only Optum360 approved clarification forms.
• Develop reciprocal relationships with HIM Coding Professionals.
• Coordinate regular meetings with HIM Coding Professionals to reconsolidate DRGs and discuss coding questions.
• Engage Physician Advisor/VPMA as needed to resolve provider issues.
• Collaborate with Care Coordination and Quality Management on CDI opportunities.

Skills

RN experience

CDI experience

Clinical knowledge

Interacting with physicians

EMR/PC skills

Education

Associate's degree

BSN preferred

CDI certifications (CCDS/CDIP/CCS)

3+ years CDI in acute care

Job description

Optum is seeking an experienced CDI specialist to review inpatient records within 24-48 hours of admission and drive documentation improvements across physicians and coding staff.

The role emphasizes frequent provider engagement, DRG reconciliation, and education to support accurate severity-of-illness coding using Optum CDI tools, with a strong focus on care coordination and quality initiatives.