CDI Specialist: Elevate Inpatient Documentation

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

Benefits offered by this job

Comprehensive benefits

Equity stock purchase

401k contribution

Job summary

Optum in Bell Gardens, California, seeks an experienced CDI professional to review inpatient records within 24-48 hours, clarifying documentation to reflect illness severity and care acuity. You will work closely with physicians to ensure accurate coding and provide education to improve documentation.

The role involves leading CDI strategies, coordinating with HIM Coding Professionals, and supporting care coordination through regular meetings and query monitoring.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital clinical RN experience OR CDI experience.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced proficiency communicating & working with Physicians.
• Intermediate PC skills in Windows environment including Word, Excel, PowerPoint and EMR.

Responsibilities

• Provides expert review of inpatient clinical records within 24-48 hours of admit for accurate code assignment.
• Identifies gaps in documentation and clarifies to reflect severity and acuity of care.
• Conducts daily follow-up with providers for documentation specificity.
• Communicates with physicians to clarify diagnoses based on severity and mortality risk.
• Performs rounding with physicians and provides DRG lists to Care Coordination.
• Delivers face-to-face educational opportunities with physicians.
• Leads education strategy development to improve clinical documentation.
• Provides timely feedback on opportunities for improvement.
• Utilizes Optum CDI tools and forms for documentation clarity.
• Coordinates with HIM Coding Professionals to reconsolidate DRGs and monitor queries.

Skills

RN acute care experience

CDI experience

Clinical medicine proficiency

Physician communication

Windows PC skills (Word/Excel/Power)

Education

Associate's degree

BSN (preferred)

Tools

Electronic Medical Records

Microsoft Word

Microsoft Excel

PowerPoint

Job description

Optum in Bell Gardens, California, seeks an experienced CDI professional to review inpatient records within 24-48 hours, clarifying documentation to reflect illness severity and care acuity. You will work closely with physicians to ensure accurate coding and provide education to improve documentation.

The role involves leading CDI strategies, coordinating with HIM Coding Professionals, and supporting care coordination through regular meetings and query monitoring.