Clinical Documentation Improvement Leader

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

Job summary

Optum is seeking a CDI-focused RN or Medical Grad with CDI experience to review inpatient records and drive documentation clarity. You will work closely with physicians to ensure accurate coding and patient risk assessment, providing education and ongoing follow-up.

The role requires strong clinical knowledge, familiarity with EMR systems, and collaboration with care coordination teams to improve documentation quality and outcomes.

Qualifications

• 5+ years of acute care hospital nursing experience or medical graduate with CDI background.
• Advanced proficiency in clinical medicine, pathophysiology and pharmacology.
• Strong communication with physicians and teams; proficient PC use (Word/Excel/PowerPoint) and EMR.

Responsibilities

• Review inpatient records within 24–48 hours of admission and identify documentation gaps.
• Clarify diagnoses with providers to ensure accurate severity and risk of mortality.
• Engage physicians and care teams to educate on documentation requirements.
• Lead physician education strategies and coordinate with HIM/CDI teams.
• Utilize CDI tools and participate in regular cross-functional meetings.

Skills

Acute care RN

CDI experience

Physician communication

MS Word/Excel/PowerPoint

Education

Associate's degree

BSN preferred

Tools

EMR / EHR systems

Job description

Optum is seeking a CDI-focused RN or Medical Grad with CDI experience to review inpatient records and drive documentation clarity. You will work closely with physicians to ensure accurate coding and patient risk assessment, providing education and ongoing follow-up.

The role requires strong clinical knowledge, familiarity with EMR systems, and collaboration with care coordination teams to improve documentation quality and outcomes.