CDI Specialist: Elevate Clinical Documentation

Jobtome; Norwalk (CT); On-site; USD 73,000 - 130,000; Full time

Job summary

UnitedHealth Group seeks a CDI-focused clinician to review inpatient records and ensure documentation reflects severity of illness and ac- curacy of coding. You will work with physicians to clarify diagnoses, lead education efforts, and coordinate with HIM teams to optimize DRG accuracy.

The role emphasizes collaboration with Care Coordination and Quality Management, using Optum 3D tools to document clarification activity and drive continuous improvement.

Qualifications

• Associate's degree required.
• 5+ years of acute care 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 skills in Windows with Word, Excel, PowerPoint and EMR.

Responsibilities

• Review inpatient clinical records within 24–48 hours of admit and identify gaps needing clarification.
• Follow up daily with providers to obtain documentation specificity.
• Communicate with providers at all levels to clarify diagnoses based on severity and risk.
• Conduct rounding with physicians and provide working DRG lists to Care Coordination.
• Lead physician education strategies to improve clinical documentation.

Skills

CDI experience

Physician communication

Electronic Medical Records

Microsoft Word

Excel

PowerPoint

Education

Associate's degree

BSN

CCDS/CDIP/CCS

Tools

CAC

EMR systems

Job description

UnitedHealth Group seeks a CDI-focused clinician to review inpatient records and ensure documentation reflects severity of illness and ac- curacy of coding. You will work with physicians to clarify diagnoses, lead education efforts, and coordinate with HIM teams to optimize DRG accuracy.

The role emphasizes collaboration with Care Coordination and Quality Management, using Optum 3D tools to document clarification activity and drive continuous improvement.