CDI Specialist: Elevate Clinical Documentation

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

Benefits offered by this job

Comprehensive benefits

Equity stock purchase

401k contribution

Incentive and recognition programs

Job summary

Optum is seeking an experienced CDI professional to review inpatient records within 24-48 hours after admission, identify documentation gaps, and work with physicians to ensure accurate coding and severity reflection.

The role requires advanced clinical knowledge, strong communication with physicians, and the ability to lead CDI education efforts across care teams. A BSN or CDI credentials are preferred, with CAC experience advantageous.

Qualifications

• Associate's degree required; RN with CDI background preferred.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Strong ability to communicate with physicians and care teams.
• Proficient in Windows-based software including Word, Excel 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.
• Clarifies diagnoses based on severity of illness and risk of mortality with physicians.
• Performs regular rounding with unit-based physicians and provides DRG lists to Care Coordination.
• Offers face-to-face educational opportunities with physicians on a regular basis.
• Leads development and execution of physician education strategies for CDI improvement.
• Coordinates with HIM Coding Professionals to reconsolidate DRGs and monitor retrospective query rates.
• Engages with Physician Advisor/VPMA to resolve provider issues in CDI processes.
• Works with Care Coordination and Quality Management on CDI opportunities and improvements.

Skills

RN experience

Clinical medicine

Pharmacology

Communication with physicians

Windows PC skills

Education

Associate's degree

BSN preferred

CDI certification (CCDS/CDIP/CCS)

CAC experience

Tools

Microsoft Word

Excel

PowerPoint

Electronic Medical Records

Job description

Optum is seeking an experienced CDI professional to review inpatient records within 24-48 hours after admission, identify documentation gaps, and work with physicians to ensure accurate coding and severity reflection.

The role requires advanced clinical knowledge, strong communication with physicians, and the ability to lead CDI education efforts across care teams. A BSN or CDI credentials are preferred, with CAC experience advantageous.