CDI Specialist: Elevate Documentation & Patient Care

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

Benefits offered by this job

Comprehensive benefits package

Equity stock purchase

401k contribution

Incentive and recognition programs

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Job summary

Optum is a global health services company seeking a CDI specialist with strong acute care experience. The role focuses on inpatient record reviews, documentation clarification, and DRG optimization to reflect severity and acuity of care.

The candidate should have an Associate degree or higher, nursing or medical background, and certifications. Expect collaboration with physicians, HIM staff, and care coordination teams in a dynamic health system.

Qualifications

• 5+ years of acute care hospital CDI or RN experience.
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced level of proficiency communicating & working closely with Physicians.
• Proficient PC use in Windows with Word, Excel, PowerPoint and EMR systems.

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit and clarifies documentation for accurate coding.
• Conducts daily follow-up with providers to obtain detailed documentation.
• Communicates with physicians to clarify diagnoses based on severity and risk of mortality.
• Performs regular rounding with unit-based physicians and provides DRG lists to Care Coordination.
• Delivers face-to-face physician education on documentation improvement strategies.
• Seeks timely clarification and recommendations for documentation improvement.
• Leads education initiatives to improve clinical documentation.
• Provides feedback on opportunities and successes in documentation.
• Ensures effective use of Optum CDI 3D technology for clarification activity.
• Uses Optum360 approved clarification forms.
• Engages HIM Coding Professionals to reconsolidate DRGs and monitor retrospective queries.
• Collaborates with Physician Advisor/VPMA to resolve provider issues in CDI process.
• Works with Care Coordination and Quality Management to drive improvement opportunities.

Skills

Acute care CDI experience

RN experience in acute care

Physician communication

Clinical medicine knowledge

Windows PC literacy

Education

Associate's degree

BSN (preferred for RN)

CCDS/CDIP/CCS certification

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Electronic Medical Records (EMR)

Job description

Optum is a global health services company seeking a CDI specialist with strong acute care experience. The role focuses on inpatient record reviews, documentation clarification, and DRG optimization to reflect severity and acuity of care.

The candidate should have an Associate degree or higher, nursing or medical background, and certifications. Expect collaboration with physicians, HIM staff, and care coordination teams in a dynamic health system.