Clinical Documentation Improvement Lead

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

Benefits offered by this job

Comprehensive benefits package

401k contribution

Equity stock purchase

Job summary

Optum in Lynwood, CA is seeking an experienced clinical professional for inpatient record review to ensure accurate code assignment within 24-48 hours of admission, reflecting severity of illness and acuity of care.

You will collaborate with physicians, educate on documentation requirements, and lead CDI initiatives using Optum tools to drive improvements. This is a full-time role with comprehensive benefits.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital clinical RN experience OR Medical Graduate with CDI experience.
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced level of proficiency communicating & working closely with Physicians.
• Intermediate level of proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records.

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
• Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
• Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
• Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
• Leads the development and execution of physician education strategies resulting in improved clinical documentation
• Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
• Ensures effective utilization of Optum CDI 3D Technology to document all clarification activity
• Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
• Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
• Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities

Skills

RN experience

CDI experience

Clinical knowledge

Physician communication

Education

Associate's degree

BSN (preferred)

Tools

Electronic Medical Records

Windows PC

Job description

Optum in Lynwood, CA is seeking an experienced clinical professional for inpatient record review to ensure accurate code assignment within 24-48 hours of admission, reflecting severity of illness and acuity of care.

You will collaborate with physicians, educate on documentation requirements, and lead CDI initiatives using Optum tools to drive improvements. This is a full-time role with comprehensive benefits.