CDI Specialist: Elevate Clinical Documentation & Outcomes

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

Benefits offered by this job

Comprehensive benefits package

Equity stock purchase

401k contribution

Job summary

Optum is a global organization delivering care aided by technology to improve health outcomes. This CDI leadership role focuses on inpatient record review within 24–48 hours of admit, identifying documentation gaps and clarifying diagnoses based on severity and risk of mortality.

Responsibilities include physician education, regular rounding with physicians, and development of CDI strategies to enhance documentation quality and accuracy across care coordination teams.

Qualifications

• Associate's degree required.
• 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 level PC skills in Windows, Word, Excel, PowerPoint and EMR.

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit and identifies documentation gaps for accurate code assignment.
• Conducts daily follow-up with providers to obtain needed documentation specificity.
• Clarifies information with providers to ensure diagnoses reflect severity and risk of mortality.
• Rounds with physicians and provides Working DRG lists to Care Coordination.
• Leads physician education strategies to improve clinical documentation.

Skills

RN experience

Physician communication

Clinical knowledge

Windows PC skills/EMR

Education

Associate's degree

BSN preferred

Tools

EMR systems

MS Office (Word/Excel/PowerPoint)

Job description

Optum is a global organization delivering care aided by technology to improve health outcomes. This CDI leadership role focuses on inpatient record review within 24–48 hours of admit, identifying documentation gaps and clarifying diagnoses based on severity and risk of mortality.

Responsibilities include physician education, regular rounding with physicians, and development of CDI strategies to enhance documentation quality and accuracy across care coordination teams.