CDI Specialist: Elevate Inpatient Documentation & Outcomes

Jobtome; Pasadena (TX); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits

Incentive programs

Equity stock purchase

401k contribution

Job summary

Optum, part of UnitedHealth Group, seeks an experienced clinician to lead inpatient clinical documentation improvement initiatives. You will review records within 24-48 hours of admission, identify documentation gaps, and collaborate with physicians to ensure accurate coding and severity reflection.

The role requires an associate degree, RN with CDI or medical graduate, strong knowledge of pathophysiology and pharmacology, and proficiency with EMR and Microsoft tools.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital clinical RN experience OR Medical Graduate with CDI experience.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced proficiency communicating with physicians and working with care teams.

Responsibilities

• Review inpatient clinical records within 24-48 hours of admission and identify documentation gaps.
• Clarify documentation with providers to ensure accurate code assignment and severity reflection.
• Conduct daily follow-up with providers to obtain documentation specificity.
• Educate physicians on documentation improvement strategies and CDI processes.
• Lead and participate in meetings with HIM Coding Professionals to monitor DRGs and clarify coding questions.

Skills

Clinical nursing

Communication with physicians

Pharmacology knowledge

Clinical medicine

Education

Associate's degree

BSN (preferred for RN)

CCDS/CDIP/CCS certification (preferred)

Tools

Microsoft Word

Microsoft Excel

PowerPoint

EMR

Job description

Optum, part of UnitedHealth Group, seeks an experienced clinician to lead inpatient clinical documentation improvement initiatives. You will review records within 24-48 hours of admission, identify documentation gaps, and collaborate with physicians to ensure accurate coding and severity reflection.

The role requires an associate degree, RN with CDI or medical graduate, strong knowledge of pathophysiology and pharmacology, and proficiency with EMR and Microsoft tools.