Clinical Documentation Improvement Specialist - Remote

UnitedHealth Group; California; Remote; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase and 401k

Job summary

The Clinical Documentation Improvement Specialist at UnitedHealth Group will provide expert coding and auditing services to ensure accurate clinical documentation and compliance with evidence-based guidelines. This full-time position in California emphasizes timely reviews and collaboration with physicians to improve documentation quality.

Responsibilities include reviewing records within 24-48 hours of admission, educating providers, tracking productivity, and leading efforts to enhance

Qualifications

• Experience communicating & working closely with Physicians.
• Experience performing concurrent inpatient chart reviews and physician query processes.
• Knowledge of inpatient reimbursement methodologies including MS-DRG and APR-DRG systems.
• Knowledge of documentation regulations, compliant query practices, and coding guidelines.

Responsibilities

• Provide expert level review of clinical records within 24-48 hours of admission.
• Conduct clear communication to providers to reinforce evidence-based guidelines.
• Effectively track productivity for accurate reporting of leading indicators.
• Provide expert level leadership for overall improvement in clinical documentation.
• Provide educational opportunities for physicians and other health care team members.
• Provide complete follow through on all requests for clarification or recommendations.
• Participate in the development and execution of education strategies.
• Provide timely feedback to providers regarding documentation opportunities.
• Engage and consult with Medical Director/leadership as needed.
• Actively engage with Care Coordination and Quality Management teams.

Skills

Communication with physicians

Inpatient chart reviews

Physician query processes

MS-DRG/APR-DRG knowledge

Documentation regulations

Education

Undergraduate degree or equivalent

Job description

About This Role

The Clinical Documentation Improvement Specialist role involves providing expert coding and auditing services to ensure accurate clinical documentation and compliance with evidence-based guidelines. This position is ideal for individuals with a strong background in clinical documentation and a passion for improving healthcare quality.

Highlights

• Pay: $72,800 - $130,000/year
• Location: Los Alamitos, CA
• Schedule: Full Time, Day shift
• Residency: Must reside in the U.S. (remote work)

What You’ll Do

• Provide expert level review of clinical records within 24-48 hours of admission.
• Conduct clear communication to providers to reinforce evidence-based guidelines.
• Effectively track productivity for accurate reporting of leading indicators.
• Provide expert level leadership for overall improvement in clinical documentation.
• Provide educational opportunities for physicians and other health care team members.
• Provide complete follow through on all requests for clarification or recommendations.
• Participate in the development and execution of education strategies.
• Provide timely feedback to providers regarding documentation opportunities.
• Engage and consult with Medical Director/leadership as needed.
• Actively engage with Care Coordination and Quality Management teams.

Requirements

Education:

• Undergraduate degree or equivalent experience

Experience:

• For RN: 3+ years acute inpatient CDI experience
• For Medical School Graduates: 2+ years of acute inpatient CDI experience
• Experience communicating & working closely with Physicians
• Experience performing concurrent inpatient chart reviews and physician query processes
• Experience working with ICD-10-CM/PCS documentation requirements
• Knowledge of inpatient reimbursement methodologies including MS-DRG and APR-DRG systems
• Knowledge of documentation regulations, compliant query practices, and coding guidelines

Licenses & Certifications:

• Current RN License or Medical School Graduate required

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase and 401k contribution

About UnitedHealth Group

UnitedHealth Group is a leading healthcare provider committed to delivering exceptional patient care. They focus on improving health outcomes and addressing health disparities through innovative health programs and services.