CDI Specialist: Inpatient Documentation & Revenue Integrity

Optum; Santa Maria (CA); On-site; USD 73,000 - 130,000; Full time

Job summary

Optum is seeking a Clinical Documentation Improvement Specialist to oversee and implement CDI processes for inpatient records at client hospitals. The role emphasizes expert chart review, provider communication, and educational leadership to ensure precise, complete documentation reflecting severity of illness and risk, leveraging Optum CDI 3D technology.

The position requires on-site work at client hospitals, with responsibilities including daily follow-up, DRG reconsolidation discussions, and

Qualifications

• 3+ years acute care hospital RN experience or Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
• Proficiency using a PC in Windows environment, including Word, Excel, PowerPoint
• Experience communicating and working closely with physicians
• Ability to work onsite

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in documentation for accurate code assignment
• Conducts daily follow-up with providers to obtain needed documentation specificity
• Leads improvement in clinical documentation and articulates rationales for recommendations
• Communicates with providers to clarify information and documentation requirements
• Develops physician education strategies to improve documentation
• Ensures effective use of Optum CDI 3D Technology and approved forms

Skills

RN experience

CDI experience

CDI certification

Physician communication

Onsite work

Education

Bachelor's degree in Nursing

CDI certification (CCDS/CDIP)

Tools

Microsoft Word

Microsoft Excel

PowerPoint

EMR systems

Job description

Optum is seeking a Clinical Documentation Improvement Specialist to oversee and implement CDI processes for inpatient records at client hospitals. The role emphasizes expert chart review, provider communication, and educational leadership to ensure precise, complete documentation reflecting severity of illness and risk, leveraging Optum CDI 3D technology.

The position requires on-site work at client hospitals, with responsibilities including daily follow-up, DRG reconsolidation discussions, and