Inpatient CDI Specialist — Elevate Clinical Documentation

Optum; South Gate (CA); On-site; USD 73,000 - 130,000; Full time

Job summary

Optum is seeking a CDI Specialist to review inpatient records promptly, identify documentation gaps, and coordinate with physicians to ensure accurate coding and severity reflection. The role focuses on improving clinical documentation through education and proactive communication.

You will partner with Care Coordination, HIM Coding, and Physician Advisors to drive improvements and leverage CDI technology for documentation accuracy.

Qualifications

• Associate degree required; RN with acute care experience or Medical Graduate with CDI experience.
• Strong clinical knowledge in medicine, pathophysiology and pharmacology.
• Excellent communication with physicians and teams; proficient PC skills including MS Word/Excel/PowerPoint/EMR.

Responsibilities

• Review inpatient records within 24–48 hours post-admit; identify documentation gaps for accurate coding.
• Follow up with providers daily to obtain clearer documentation.
• Educate physicians on documentation requirements to support diagnoses based on severity.

Skills

Inpatient RN experience

Physician communication

Documentation proficiency

Education

Associate's degree

BSN preferred (RN)

Tools

EMR systems

Microsoft Word

Excel

PowerPoint

Job description

Optum is seeking a CDI Specialist to review inpatient records promptly, identify documentation gaps, and coordinate with physicians to ensure accurate coding and severity reflection. The role focuses on improving clinical documentation through education and proactive communication.

You will partner with Care Coordination, HIM Coding, and Physician Advisors to drive improvements and leverage CDI technology for documentation accuracy.