Onsite CDI Specialist: Elevate Clinical Documentation

UnitedHealth Group; Santa Maria (CA); On-site; Confidential; Full time

Benefits offered by this job

Benefits package

Equity stock purchase program

Job summary

UnitedHealth Group's Optum Insight team is seeking a Clinical Document Improvement Specialist (CDS) to oversee CDI programs and implement processes for inpatient documentation. You will work with providers to ensure accurate, complete coding reflecting severity of illness and care decisions.

The role requires 3+ years of acute care RN experience or equivalent CDI background, onsite work, and CDI certifications like CCDS/CDIP.

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, Power Point and electronic medical records
• Experience communicating & working closely with physicians
• Ability to work onsite

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
• 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 activities

Skills

RN experience

Physician communication

CDI experience

Onsite work

Education

RN license

CDI certification (CCDS/CDIP)

Tools

Windows

Microsoft Word

Microsoft Excel

PowerPoint

Job description

UnitedHealth Group's Optum Insight team is seeking a Clinical Document Improvement Specialist (CDS) to oversee CDI programs and implement processes for inpatient documentation. You will work with providers to ensure accurate, complete coding reflecting severity of illness and care decisions.

The role requires 3+ years of acute care RN experience or equivalent CDI background, onsite work, and CDI certifications like CCDS/CDIP.