Lead Inpatient CDI & Documentation Improvement

Optum; Bakersfield (CA); On-site; USD 100,289,000 - 180,521,000; Full time

Benefits offered by this job

Benefits package

Incentives and recognition programs

Equity stock purchase

401k contribution

Job summary

Optum Insight is seeking a Clinical Document Improvement Specialist (CDS) to oversee CDI programs and implement CDI processes across inpatient records for Optum 360 clients. The CDS will use Optum 3D CDI technology to enhance data quality, accuracy, and revenue integrity.

The role requires collaboration with physicians and care teams, timely reviews within 24–48 hours of admission, and leadership in documenting severity of illness and risk of mortality.

Qualifications

• 3+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
• Experience communicating & working closely with Physicians
• Proficiency using a PC in a Windows environment, including Word, Excel, PowerPoint and EMRs

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in documentation
• Conducts daily follow-up with providers to obtain needed documentation specificity
• Provides expert leadership for overall improvement in clinical documentation and articulates recommendations with rationale
• Communicates with providers at all levels to clarify information and documentation requirements
• Performs regular rounding with physicians and provides Working DRG lists to Care Coordination
• Leads physician education strategies to improve clinical documentation

Skills

RN experience

CDI certification

Physician communication

MS Office (Word, Excel, PowerPoint)

Education

Nursing degree (RN)

CDI Certification (CCDS/CDIP)

Tools

EMR systems

Windows PC

Job description

Optum Insight is seeking a Clinical Document Improvement Specialist (CDS) to oversee CDI programs and implement CDI processes across inpatient records for Optum 360 clients. The CDS will use Optum 3D CDI technology to enhance data quality, accuracy, and revenue integrity.

The role requires collaboration with physicians and care teams, timely reviews within 24–48 hours of admission, and leadership in documenting severity of illness and risk of mortality.