CDI Specialist: Elevate Inpatient Documentation

Optum; Eagle Rock (NC); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits

401k contribution

Job summary

Optum is seeking an experienced CDI professional to review inpatient records and identify documentation gaps within 24-48 hours of admission. You will collaborate with physicians to clarify diagnoses, round with care teams, and drive documentation improvement initiatives across the organization.

Responsibilities include educating providers, coordinating with HIM Coding Professionals, and leveraging Optum CDI tools to ensure accurate coding and risk assessment.

Qualifications

• 5+ years of acute care hospital clinical RN experience or CDI experience as a Medical Graduate.
• Strong understanding of clinical medicine, pathophysiology, and pharmacology.
• Experience communicating with physicians and coordinating documentation improvement.

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit to guide coding accuracy.
• Follow up with providers daily to obtain documentation specificity.
• Clarify diagnoses based on illness severity and mortality risk.
• Round with unit physicians and provide Working DRG lists to Care Coordination.
• Educate physicians regularly on documentation improvements.
• Provide timely feedback on documentation opportunities and successes.
• Lead development and execution of physician education strategies.
• Collaborate with HIM Coding Professionals to reconsolidate DRGs.

Skills

RN experience

Clinical expertise

Physician communication

PC skills

Education

Associate degree

BSN preferred

Tools

EMR systems

Microsoft Office

Windows PC

Job description

Optum is seeking an experienced CDI professional to review inpatient records and identify documentation gaps within 24-48 hours of admission. You will collaborate with physicians to clarify diagnoses, round with care teams, and drive documentation improvement initiatives across the organization.

Responsibilities include educating providers, coordinating with HIM Coding Professionals, and leveraging Optum CDI tools to ensure accurate coding and risk assessment.