CDI Specialist: Elevate Care Through Documentation

Jobtome; Vernon (TX); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits

Equity stock purchase plan

401k contribution

Incentive programs

Job summary

UnitedHealth Group is seeking a CDI Specialist to review inpatient medical records, identify documentation gaps, and collaborate with physicians to ensure accurate coding and proper severity assessment. The role requires strong clinical knowledge and physician communication skills, with adeptness in EMR systems and MS Office.

The position emphasizes CDI program leadership, education strategies for clinicians, and coordination with HIM and Care Coordination teams to improve documentation quality

Qualifications

• CDI experience in acute care settings is required.
• Strong clinical knowledge across medicine, pathophysiology, and pharmacology.
• Excellent communication with physicians and care teams is essential.

Responsibilities

• Review inpatient records within 24–48 hours of admit and identify documentation gaps.
• Clarify documentation with providers to ensure accurate coding and reflect severity.
• Lead physician education on documentation improvement strategies.
• Coordinate with HIM Coding Professionals, Care Coordination, and Quality Management.
• Escalate issues with Physician Advisor/VPMA as needed to resolve clarifications.
• Drive ongoing CDI initiatives to improve health outcomes.

Skills

CDI experience

Clinical knowledge

Physician communication

EMR proficiency

Education

Associate's degree

BSN preferred

CCDS/CDIP/CCS

Tools

EMR / EHR systems

MS Word / Excel / PowerPoint

Job description

UnitedHealth Group is seeking a CDI Specialist to review inpatient medical records, identify documentation gaps, and collaborate with physicians to ensure accurate coding and proper severity assessment. The role requires strong clinical knowledge and physician communication skills, with adeptness in EMR systems and MS Office.

The position emphasizes CDI program leadership, education strategies for clinicians, and coordination with HIM and Care Coordination teams to improve documentation quality