CDI Specialist: Elevate Clinical Documentation & Outcomes

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

Benefits offered by this job

Comprehensive benefits

Incentive programs

Equity stock purchase

401k contribution

Job summary

Optum is seeking a CDI Specialist to review inpatient clinical records within 24-48 hours of admission and identify gaps to ensure accurate coding reflecting severity of illness. You will follow up with providers daily to obtain documentation specificity and educate physicians on CDI best practices.

The role requires advanced clinical knowledge, strong physician communication, and proficiency with EMR systems.

Qualifications

• Associate's degree required with clinical background in acute care.
• Advanced level proficiency in clinical medicine, pathophysiology, and pharmacology.
• Strong communication skills with Physicians and other providers.
• Proficient PC skills and EMR usage (Word, Excel, PowerPoint).

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit to ensure accurate code assignment.
• Conducts daily follow-up with providers to obtain documentation specificity.
• Communicates with providers to clarify diagnoses based on severity and risk of mortality.
• Performs rounding with physicians and provides Working DRG lists to Care Coordination.
• Delivers face-to-face education to physicians on clinical documentation improvement.
• Leads development and execution of physician education strategies for improved documentation.
• Partners with HIM Coding Professionals to reconsolidate DRGs and monitor retrospective query rates.
• Engages with Physician Advisor / VPMA to resolve provider issues in documentation and CDI processes.
• Collaborates with Care Coordination and Quality Management to pursue CDI opportunities.

Skills

Acute care RN experience

Physician communication

EMR proficiency

Education

Associate's degree

BSN preferred

CCDS/CDIP/CCS certification

3+ years CDI experience (acute care)

CAC experience

Tools

Electronic Medical Records (EMR)

Job description

Optum is seeking a CDI Specialist to review inpatient clinical records within 24-48 hours of admission and identify gaps to ensure accurate coding reflecting severity of illness. You will follow up with providers daily to obtain documentation specificity and educate physicians on CDI best practices.

The role requires advanced clinical knowledge, strong physician communication, and proficiency with EMR systems.