CDI Specialist: Elevate Clinical Documentation

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

Job summary

Optum is seeking a CDI Specialist to review inpatient records within 24-48 hours of admission, identify documentation gaps, and ensure accurate code assignment reflecting illness severity. You will work with physicians to clarify diagnoses and coordinate with care teams to improve documentation.

The role requires an associate degree and 5+ years acute care RN or CDI experience, strong clinical knowledge, and proficiency with EMR and MS Office.

Qualifications

• Associate's degree and 5+ years of acute care hospital clinical RN experience OR Medical Graduate with CDI experience.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced proficiency communicating and working closely with Physicians.
• Intermediate PC proficiency in Windows environment including Word, Excel, PowerPoint and EMR systems.

Responsibilities

• Review inpatient records within 24-48 hours to identify documentation gaps for accurate code assignment.
• Daily follow-up with providers to obtain needed documentation specificity.
• Clarify diagnoses based on severity of illness and risk of mortality with physicians.
• Lead physician education strategies to improve clinical documentation.
• Coordinate with HIM Coding Professionals to reconsolidate DRGs and monitor retrospective query rates.

Skills

RN experience

Physician communication

Clinical medicine

PC proficiency

Education

Associate's degree

BSN (preferred)

CAC experience (optional)

CCDS/CDIP/CCS (certification)

Tools

EMR systems

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Job description

Optum is seeking a CDI Specialist to review inpatient records within 24-48 hours of admission, identify documentation gaps, and ensure accurate code assignment reflecting illness severity. You will work with physicians to clarify diagnoses and coordinate with care teams to improve documentation.

The role requires an associate degree and 5+ years acute care RN or CDI experience, strong clinical knowledge, and proficiency with EMR and MS Office.