CDI Specialist — Elevate Documentation & Clinical Outcomes

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

Benefits offered by this job

Comprehensive benefits package

Incentive programs

Equity stock purchase

401k contribution

Job summary

Optum is seeking a CDI-focused professional to review inpatient records within 24-48 hours of admission, identify documentation gaps, and drive clinical documentation improvement. The role emphasizes collaboration with physicians, HIM Coding Professionals, and care teams to ensure accurate diagnoses and severity of illness.

The position requires strong clinical background, CDI experience or acute care RN experience, and proficiency with Microsoft Office and EMR systems.

Qualifications

• Must have relevant clinical education with RN background or CDI experience.
• Proficient in medical terminology, documentation guidelines, and coding concepts.
• Experienced in communicating with physicians and hospital staff.

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit.
• Conducts daily follow-up with providers to obtain documentation specificity.
• Communicates with physicians to clarify diagnoses based on severity of illness and risk of mortality.
• Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination.
• Delivers physician education on documentation improvement strategies.
• Ensures utilization of Optum CDI 3D technology and standardized clarification forms.
• Collaborates with HIM Coding Professionals and Physician Advisor/VPMA as needed.
• Partners with Care Coordination and Quality Management to drive CDI opportunities.

Education

Associate's degree

BSN degree if a RN

CCDS, CDIP or CCS certification

3+ years of CDI experience for an acute care hospital

CAC experience (Computer Assistant Coding)

Tools

Microsoft Word

Excel

PowerPoint

Electronic Medical Records

Job description

Optum is seeking a CDI-focused professional to review inpatient records within 24-48 hours of admission, identify documentation gaps, and drive clinical documentation improvement. The role emphasizes collaboration with physicians, HIM Coding Professionals, and care teams to ensure accurate diagnoses and severity of illness.

The position requires strong clinical background, CDI experience or acute care RN experience, and proficiency with Microsoft Office and EMR systems.