Remote CDI Specialist: Clinical Documentation Expert

RXinsider LTD.; Bakersfield (CA); Remote; USD 60,000 - 107,000; Full time

Benefits offered by this job

Benefits package

Job summary

UnitedHealth Group's Optum CDI team seeks an Associate Clinical Document Improvement Specialist to oversee CDI activities for inpatients, ensuring precise, complete documentation and accurate coding. This role emphasizes collaboration with physicians and coding professionals, and leverages CDI 3D technology.

The position offers remote work within the U.S., competitive salary, and a comprehensive benefits package, with opportunities for professional development and impact on patient care quality.

Qualifications

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

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit and identifies gaps in documentation for accurate code assignment
• Conducts daily follow-up communication with providers to obtain needed documentation specificity
• Leads improvement efforts in clinical documentation and communicates recommendations with rationale
• Communicates with providers at all levels to clarify information and documentation requirements
• Performs rounding with unit-based physicians and provides Working DRG lists to Care Coordination
• Provides educational opportunities with physicians on a regular basis
• Follows up on clarification requests and recommendations for improvement
• Leads development and execution of physician education strategies for improved documentation
• Provides timely feedback to providers on documentation opportunities and successes
• Ensures effective utilization of Optum CDI 3D Technology and approved forms
• Develops reciprocal relationship with HIM Coding Professionals and coordinates regular meetings
• Engages with Physician Advisor/VPMA when needed to resolve clarification issues
• Collaborates with Care Coordination and Quality Management to pursue CDI improvements

Skills

RN experience

CDI experience

Physician communication

Education

Nursing degree (RN)

CDDS, CDIP or CCS certification

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Electronic Medical Records (EMR)

Job description

UnitedHealth Group's Optum CDI team seeks an Associate Clinical Document Improvement Specialist to oversee CDI activities for inpatients, ensuring precise, complete documentation and accurate coding. This role emphasizes collaboration with physicians and coding professionals, and leverages CDI 3D technology.

The position offers remote work within the U.S., competitive salary, and a comprehensive benefits package, with opportunities for professional development and impact on patient care quality.