Impactful CDI Specialist — Elevate Clinical Documentation

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

Benefits offered by this job

Comprehensive benefits

Incentives and recognition programs

Equity stock purchase

401k contribution

Job summary

Optum Insight is seeking a Clinical Document Improvement Specialist (CDS) to oversee and implement CDI processes for inpatient records at Optum 360 clients. The CDS ensures documentation accurately reflects clinical findings, treatments, and diagnoses while using CDI 3D technology to improve data quality and revenue integrity.

Responsibilities include expert record reviews within 24–48 hours of admission, proactive provider communication, and leadership in CDI improvements.

Qualifications

• 3+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
• Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, PowerPoint
• Ability to work onsite at client hospital

Responsibilities

• Provides expert level review of inpatient records within 24-48 hours after admit, identifying gaps needing clarification for accurate coding
• Conducts daily follow-up with providers to obtain needed documentation specificity
• Leads overall improvement in clinical documentation and communicates recommendations with rationale
• Communicates with providers at all levels to clarify information and documentation requirements
• Coordinates and conducts regular meetings with HIM Coding Professionals to reconsolidate DRGs and discuss coding questions

Skills

Physician communication

Onsite work

MS Office

Education

RN with acute care experience

Medical degree with CDI certification

Job description

Optum Insight is seeking a Clinical Document Improvement Specialist (CDS) to oversee and implement CDI processes for inpatient records at Optum 360 clients. The CDS ensures documentation accurately reflects clinical findings, treatments, and diagnoses while using CDI 3D technology to improve data quality and revenue integrity.

Responsibilities include expert record reviews within 24–48 hours of admission, proactive provider communication, and leadership in CDI improvements.