Clinical Documentation Improvement Leader

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

Benefits offered by this job

Comprehensive benefits package

Equity stock purchase program

401(k) contribution

Incentive and recognition programs

Job summary

Optum is seeking a CDI-focused professional to review inpatient records and drive documentation improvements. You will promptly identify gaps, clarify with physicians, and guide diagnoses to reflect severity and mortality risk.

Advanced clinical knowledge and strong communication with physicians are essential, along with proficiency in EMR and Microsoft Office tools. This role emphasizes collaboration with Care Coordination and HIM teams.

Qualifications

• Associate's degree required; BSN preferred for RN background.
• 5+ years acute care hospital RN experience or CDI-experienced medical graduate.
• Advanced proficiency in medicine, pathophysiology and pharmacology.
• Strong communication with physicians; proficiency with Windows PC tools.
• Experience with EMR systems and Microsoft Office applications.

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit to identify documentation gaps.
• Clarify documentation needs with providers to reflect severity and acuity.
• Communicate with physicians at all levels about diagnoses based on severity.
• Perform rounding with physicians and provide Working DRG lists to Care Coordination.
• Educate physicians regularly on clinical documentation improvement.
• Ensure use of Optum CDI 3D technology and approved clarification forms.
• Coordinate with HIM Coding Professionals; monitor retrospective query rates.
• Engage with Physician Advisor / VPMA as needed to resolve issues.

Skills

Acute care nursing experience

CDI knowledge

Physician communication

PC proficiency

Education

Associate's degree

BSN preferred

CCDS/CDIP/CCS certification

CAC experience

3+ years CDI experience

Tools

EMR

Microsoft Word

Microsoft Excel

PowerPoint

Job description

Optum is seeking a CDI-focused professional to review inpatient records and drive documentation improvements. You will promptly identify gaps, clarify with physicians, and guide diagnoses to reflect severity and mortality risk.

Advanced clinical knowledge and strong communication with physicians are essential, along with proficiency in EMR and Microsoft Office tools. This role emphasizes collaboration with Care Coordination and HIM teams.