CDI Specialist: Elevate Inpatient Documentation & Revenue

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

Benefits offered by this job

Comprehensive benefits

Incentive programs

Stock purchase plan

401k contribution

Job summary

Optum is seeking a Clinical Document Improvement Specialist to oversee CDI programs and implement CDI processes for inpatient records at Optum 360 clients. The role focuses on accuracy, specificity, and completeness of documentation to reflect treatments, decisions, and diagnoses.

The CDS uses Optum CDI 3D technology and collaborates with providers to improve data quality and revenue integrity. This on-site role includes leadership, education, and cross-functional collaboration to drive CDI

Qualifications

• 3+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP).
• Proficiency using PC in Windows, including Word, Excel, PowerPoint and EMR.
• Experience communicating & working closely with physicians.

Responsibilities

• Provide expert level review of inpatient clinical records within 24–48 hours of admit.
• Identify gaps in clinical documentation for accurate code assignment.
• Lead improvement in clinical documentation with recommendations and rationale.
• Communicate documentation requirements for diagnoses based on illness severity and risk.
• Perform rounding with physicians and provide Working DRG lists to Care Coordination.
• Lead physician education strategies to improve documentation.

Skills

RN clinical experience

CDI experience

Communication with physicians

Onsite work

Education

BSN degree

CDDS/CDIP/CCS certification

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Job description

Optum is seeking a Clinical Document Improvement Specialist to oversee CDI programs and implement CDI processes for inpatient records at Optum 360 clients. The role focuses on accuracy, specificity, and completeness of documentation to reflect treatments, decisions, and diagnoses.

The CDS uses Optum CDI 3D technology and collaborates with providers to improve data quality and revenue integrity. This on-site role includes leadership, education, and cross-functional collaboration to drive CDI