Clinical Documentation Improvement Expert

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

Benefits offered by this job

Comprehensive benefits package

401(k) plan

Equity stock purchase

Job summary

Optum is seeking a Clinical Documentation Improvement (CDI) Specialist with RN background or medical graduate. You will review inpatient records within 24-48 hours of admission, clarify documentation with providers, and lead education to improve coding and documentation accuracy.

The role involves collaboration with HIM Coding Professionals, Care Coordination, and physician leaders, using CDI tools to optimize DRG accuracy, and participating in ongoing education initiatives.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital RN experience or Medical Graduate CDI experience.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Strong communication with physicians.
• MS Office and EMR proficiency.

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit to ensure accurate code assignment.
• Clarify documentation with providers to reflect severity and acuity of care.
• Lead physician education strategies to improve clinical documentation and coding.
• Collaborate with HIM Coding Professionals, Care Coordination, and Quality Management teams.
• Engage with Physician Advisor/VPMA to resolve provider issues and escalation cases.

Skills

Clinical medicine expertise

Physician communication

EMR navigation

Education

Associate's degree

BSN preferred

CCDS/CDIP/CCS certification

Tools

Electronic Medical Records

Job description

Optum is seeking a Clinical Documentation Improvement (CDI) Specialist with RN background or medical graduate. You will review inpatient records within 24-48 hours of admission, clarify documentation with providers, and lead education to improve coding and documentation accuracy.

The role involves collaboration with HIM Coding Professionals, Care Coordination, and physician leaders, using CDI tools to optimize DRG accuracy, and participating in ongoing education initiatives.