CDI Specialist: Elevate Clinical Documentation & Outcomes

Jobtome; Eagle Rock (NC); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits

Incentives program

Equity stock purchase

401k plan

Job summary

Optum is a global health services company seeking a CDI Specialist to review inpatient records, clarify documentation, and educate physicians to improve coding accuracy. The role emphasizes collaboration with care teams, HIM professionals, and leadership in documentation improvement.

Qualified candidates have an associate degree and several years of acute care CDI experience, with strong clinical knowledge and physician communication skills.

Qualifications

• Associate degree required; RN with 5+ years acute care experience or medical graduate with CDI experience.
• Advanced knowledge of clinical medicine, pathophysiology and pharmacology.
• Strong communication with physicians and teams; proficient PC skills.

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit and identify documentation gaps for accurate coding.
• Conduct daily follow-up with providers to obtain needed documentation specificity.
• Clarify diagnoses based on illness severity and mortality risk, communicating requirements clearly.
• Perform regular rounding with unit-based physicians and provide DRG lists for Care Coordination.
• Lead physician education strategies to improve clinical documentation accuracy.
• Provide timely feedback on opportunities for improvement in clinical documentation.
• Coordinate with HIM Coding Professionals and reconsolidate DRGs as needed.

Skills

Clinical knowledge

Physician communication

EMR proficiency

Windows Office familiarity

Education

Associate's degree

BSN degree

CCDS/CDIP/CCS certification

Tools

CAC experience

Job description

Optum is a global health services company seeking a CDI Specialist to review inpatient records, clarify documentation, and educate physicians to improve coding accuracy. The role emphasizes collaboration with care teams, HIM professionals, and leadership in documentation improvement.

Qualified candidates have an associate degree and several years of acute care CDI experience, with strong clinical knowledge and physician communication skills.