CDI Specialist: Elevate Documentation & Physician Education

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

Job summary

Optum in the United States is seeking a CDI professional to enhance clinical documentation. The role involves reviewing inpatient records within 24-48 hours of admission, guiding accurate code assignment, and communicating documentation requirements to physicians.

You will lead education strategies for clinicians, coordinate with HIM Coding Professionals, and collaborate with Care Coordination and Quality Management to drive documentation improvements.

Qualifications

• Associate's degree
• 5+ years of acute care hospital clinical RN experience OR Medical Graduate with CDI experience
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology
• Advanced level of proficiency communicating & working closely with Physicians
• Intermediate level of proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records

Responsibilities

• Reviews inpatient clinical records within 24-48 hours of admit to ensure accurate coding and reflects severity of condition
• Conducts daily follow-up with providers to obtain documentation specificity
• Clarifies diagnoses based on severity of illness and risk of mortality
• Performs regular rounding with unit-based physicians and provides DRG lists to Care Coordination
• Provides face-to-face educational opportunities with physicians
• Completes follow-through on requests for clarification or recommendations for improvement
• Leads development and execution of physician education strategies for CDI
• Provides timely feedback to providers regarding opportunities for improvement
• Ensures effective use of Optum CDI technology and standardized clarification forms
• Develops relationships with HIM Coding Professionals and coordinates regular meetings
• Engages Physician Advisor/VPMA as needed to resolve provider issues
• Collaborates with Care Coordination and Quality Management to drive CDI opportunities

Skills

Clinical knowledge

Physician communication

EMR proficiency

MS Office proficiency

Education

Associate's degree

BSN preferred

Tools

Microsoft Word

Excel

PowerPoint

Electronic Medical Records

Job description

Optum in the United States is seeking a CDI professional to enhance clinical documentation. The role involves reviewing inpatient records within 24-48 hours of admission, guiding accurate code assignment, and communicating documentation requirements to physicians.

You will lead education strategies for clinicians, coordinate with HIM Coding Professionals, and collaborate with Care Coordination and Quality Management to drive documentation improvements.