Inpatient CDI Specialist - Clinical Documentation Expert

Jobtome; La Cañada Flintridge (CA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits

401k plan

Equity stock purchase

Job summary

Optum, a global health services company, is seeking a CDI-focused clinical professional to review inpatient records and ensure documentation accurately reflects severity of illness and acuity of care.

You will lead physician education, collaborate with HIM Coding Professionals, and coordinate with Care Coordination to drive continuous improvement in clinical documentation. A strong RN background or physician-turned-CDI with CDI experience is preferred.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital RN experience OR Medical Graduate with CDI experience.
• Advanced level of proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced level of proficiency communicating with Physicians.
• Proficient in Windows environment and EMR systems.

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 documentation specificity.
• Communicates with providers at all levels to clarify information and documentation requirements.
• Leads the development and execution of physician education strategies to improve clinical documentation.
• Engages with Care Coordination and Quality Management to drive CDI opportunities.

Skills

RN experience

Acute care

CDI experience

Physician communication

Education

Associate's degree

BSN preferred

Tools

EMR systems

Microsoft Word

Excel

PowerPoint

Job description

Optum, a global health services company, is seeking a CDI-focused clinical professional to review inpatient records and ensure documentation accurately reflects severity of illness and acuity of care.

You will lead physician education, collaborate with HIM Coding Professionals, and coordinate with Care Coordination to drive continuous improvement in clinical documentation. A strong RN background or physician-turned-CDI with CDI experience is preferred.