CDI Specialist: Elevate Patient Care through Documentation

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

Benefits offered by this job

Comprehensive benefits

Job summary

Optum is seeking a CDI specialist to review inpatient records and identify documentation gaps that affect coding accuracy. You will engage physicians to clarify clinical details, ensuring severity and acuity are properly reflected.

The role emphasizes collaboration with Care Coordination, HIM Coding Professionals, and physician advisors to drive ongoing clinical documentation improvement and compliance.

Qualifications

• Associate's degree required; RN with CDI experience accepted.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Excellent communication and collaboration with Physicians.

Responsibilities

• Review inpatient records within 24-48 hours of admission to determine appropriate documentation.
• Communicate clarifications with providers to improve documentation accuracy and coding.
• Lead physician education initiatives to optimize clinical documentation improvement.
• Coordinate with HIM Coding Professionals and CDI teams on DRG reconciliation and queries.

Skills

Clinical knowledge

Physician communication

EMR proficiency

Education

Associate's degree

BSN preferred

Tools

MS Office

Job description

Optum is seeking a CDI specialist to review inpatient records and identify documentation gaps that affect coding accuracy. You will engage physicians to clarify clinical details, ensuring severity and acuity are properly reflected.

The role emphasizes collaboration with Care Coordination, HIM Coding Professionals, and physician advisors to drive ongoing clinical documentation improvement and compliance.