CDI Specialist: Elevate Clinical Documentation

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

Job summary

Optum in the United States seeks an experienced CDI Specialist to review inpatient records and improve clinical documentation. You will identify gaps, clarify diagnoses, and educate physicians to reflect severity of illness and risk of mortality.

In this role, expect collaboration with HIM CDI teams, Care Coordination, and physicians, with a focus on timely documentation improvements and effective use of Optum CDI technology.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital clinical RN experience or Medical Graduate CDI experience.
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced level of proficiency communicating with physicians.
• Proficiency with Windows PC and MS Word, Excel, PowerPoint and EMR.

Responsibilities

• Review inpatient clinical records within 24–48 hours of admit to ensure accurate coding.
• Identify gaps in documentation requiring clarification.
• Communicate with providers to obtain documentation specificity.
• Educate physicians on documentation improvement strategies.
• Collaborate with HIM CDI, Care Coordination and QA teams.

Skills

Clinical knowledge & physician comms

Medical terminology

EMR proficiency

Documentation follow-up

Education

Associate's degree

BSN preferred (RN)

CCDS/CDIP/CCS certifications

Tools

Microsoft Word

Excel

PowerPoint

EMR systems

Job description

Optum in the United States seeks an experienced CDI Specialist to review inpatient records and improve clinical documentation. You will identify gaps, clarify diagnoses, and educate physicians to reflect severity of illness and risk of mortality.

In this role, expect collaboration with HIM CDI teams, Care Coordination, and physicians, with a focus on timely documentation improvements and effective use of Optum CDI technology.