Clinical Documentation Improvement Expert

Jobtome; Fullerton (CA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

401k contribution

Job summary

Optum is hiring a clinical documentation improvement specialist to review inpatient records and ensure accurate code assignment. You will work closely with physicians, perform rounding with unit-based physicians, and lead education initiatives to improve documentation quality.

The role requires strong CDI experience, RN or MD background, and excellent communication with care teams. Comprehensive benefits and growth opportunities are offered by Optum.

Qualifications

• Associate's degree required; 5+ years acute care RN experience OR medical graduate with CDI experience.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Strong communication with physicians and ability to educate clinicians.

Responsibilities

• Review inpatient clinical records within 24–48 hours of admit; identify documentation gaps for accurate coding.
• Follow up with providers daily to obtain documentation specificity.
• Lead physician education strategies to improve clinical documentation.

Skills

RN experience

CDI experience

Physician communication

Education

Associate's degree

BSN preferred

Tools

Microsoft Word

Excel

PowerPoint

Electronic Medical Records

Job description

Optum is hiring a clinical documentation improvement specialist to review inpatient records and ensure accurate code assignment. You will work closely with physicians, perform rounding with unit-based physicians, and lead education initiatives to improve documentation quality.

The role requires strong CDI experience, RN or MD background, and excellent communication with care teams. Comprehensive benefits and growth opportunities are offered by Optum.