Onsite CDI Specialist – Clinical Documentation Leader

Optum; Los Angeles (CA); On-site; USD 73,000 - 130,000; Full time

Job summary

Optum is seeking a Clinical Documentation Integrity Specialist to lead inpatient record reviews, identify documentation gaps, and collaborate with physicians to ensure accurate coding and patient care reflection. This onsite role in downtown Los Angeles emphasizes leadership, education, and the use of CDI best practices along with Optum 3D technology.

The position prioritizes timely clarification, DRG accuracy, and revenue integrity, with a focus on improving documentation quality across Optum

Qualifications

• 5+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
• Experience communicating & working closely with Physicians
• Must have proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records
• Ability to work onsite Mon-Fri, ~ 8-4:30pm, downtown Los Angeles

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
• Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
• Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations
• Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
• Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
• Provides face-to-face educational opportunities with physicians on a regular basis
• Provides complete follow through on all requests for clarification or recommendations for improvement
• Leads the development and execution of physician education strategies resulting in improved clinical documentation
• Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
• Ensures effective utilization of Optum CDI 3D Technology to document all clarification activity
• Utilizes only the Optum360 approved clarification forms
• Proactively develops a reciprocal relationship with the HIM Coding Professionals
• Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
• Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
• Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities

Skills

RN clinical experience

Physician communication

PC proficiency (Windows, Word, Excel)

Onsite availability

Education

BSN degree

Tools

EMR systems

MS Office (Word, Excel, PowerPoint)

Job description

Optum is seeking a Clinical Documentation Integrity Specialist to lead inpatient record reviews, identify documentation gaps, and collaborate with physicians to ensure accurate coding and patient care reflection. This onsite role in downtown Los Angeles emphasizes leadership, education, and the use of CDI best practices along with Optum 3D technology.

The position prioritizes timely clarification, DRG accuracy, and revenue integrity, with a focus on improving documentation quality across Optum