Clinical Documentation Improvement Leader (Onsite Honolulu)

UnitedHealth Group; Honolulu (HI); On-site; Confidential; Full time

Job summary

UnitedHealth Group's Optum Insight is seeking a Clinical Document Improvement Specialist to oversee CDI programs and implement inpatient CDI processes. The role focuses on accurate, complete documentation of patient conditions and treatments to support proper coding and reimbursement.

The CDS collaborates with physicians and healthcare teams, leveraging CDI 3D technology to drive quality, compliance, and revenue integrity across Optum 360 clients.

Qualifications

• Must have Hawaii RN license currently or within 90 days of hire.
• 5+ years acute care hospital RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP).
• Experience communicating and working closely with Physicians.
• Proficiency in Windows environment including Word, Excel, PowerPoint and EMR.

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in documentation for accurate code assignment.
• Conducts daily follow-up with providers to obtain needed documentation specificity.
• Leads CDI improvement initiatives and articulate recommendations with rationale.
• Communicates with providers at all levels to clarify information for diagnoses based on illness severity.
• Performs regular rounding with physicians and provides DRG lists to Care Coordination.
• Delivers face-to-face physician education on a regular basis.
• Follows up on all requests for clarification or improvement recommendations.
• Leads development and execution of physician education strategies to improve documentation.
• Provides timely feedback on opportunities for improvement and successes.
• Ensures effective use of Optum CDI 3D Technology and approved clarification forms.
• Develops reciprocal relationships with HIM Coding Professionals and coordinates regular meetings.

Skills

Communication with physicians

MS Office proficiency

EMR proficiency

Education

BSN preferred

CDS/CDIP/CCDS certification

Clinical Documentation Improvement experience

Tools

Microsoft Office Suite

Electronic Medical Records (EMR)

Job description

UnitedHealth Group's Optum Insight is seeking a Clinical Document Improvement Specialist to oversee CDI programs and implement inpatient CDI processes. The role focuses on accurate, complete documentation of patient conditions and treatments to support proper coding and reimbursement.

The CDS collaborates with physicians and healthcare teams, leveraging CDI 3D technology to drive quality, compliance, and revenue integrity across Optum 360 clients.