Clinical Documentation Improvement Lead

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

Job summary

Optum is hiring for a CDI-focused role reviewing inpatient records to ensure accurate coding and documentation. You will communicate with physicians, coordinate with HIM and Care Coordination teams, and lead education initiatives to improve documentation quality.

Ideal candidates have 5+ years in acute care nursing or CDI, strong clinical knowledge, and proficient EMR skills. Remote/in-office flexibility may apply within California.

Qualifications

• Associate's degree required.
• 5+ years acute care RN or CDI experience considered.
• Advanced level proficiency in clinical medicine, pathophysiology, pharmacology.
• Advanced level of proficiency communicating with Physicians.
• Intermediate PC skills: Word, Excel, PowerPoint, EMR.

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit and identifies gaps for accurate code assignment.
• Performs regular rounding with physicians and provides DRG lists to Care Coordination.
• Leads physician education strategies to improve clinical documentation.
• Coordinates with HIM Coding Pros and follows escalation processes to resolve clarification issues.
• Engages Care Coordination and Quality Management to drive CDI opportunities.

Skills

CDI experience

Advanced clinical knowledge

Physician communication

EMR proficiency

Education

Associate's degree

BSN

Tools

Microsoft Word

Excel

PowerPoint

Electronic Medical Records

Job description

Optum is hiring for a CDI-focused role reviewing inpatient records to ensure accurate coding and documentation. You will communicate with physicians, coordinate with HIM and Care Coordination teams, and lead education initiatives to improve documentation quality.

Ideal candidates have 5+ years in acute care nursing or CDI, strong clinical knowledge, and proficient EMR skills. Remote/in-office flexibility may apply within California.