Remote CDI Specialist: Elevate Clinical Documentation

RXinsider LTD.; Los Alamitos (CA); Remote; USD 73,000 - 130,000; Full time

Benefits offered by this job

Benefits package

Equity stock purchase

401k contribution

Remote work flexibility

Job summary

UnitedHealth Group is seeking a clinical documentation integrity (CDI) specialist to review medical records within 24-48 hours of admission and collaborate with physicians to ensure alignment with evidence-based guidelines.

The role supports remote work from anywhere in the U.S., with a comprehensive benefits package and pathways for education and career growth.

Required qualifications include nursing or medical degree, CDI experience, and knowledge of ICD-10-CM/PCS and MS-DRG systems.

Qualifications

• Undergraduate degree or equivalent experience.
• Current RN License or Medical School Graduate.
• For RN: 3+ years acute inpatient CDI experience.
• For Medical School Graduates: 2+ years acute inpatient CDI experience.
• Experience communicating & working closely with Physicians.
• Experience performing concurrent inpatient chart reviews and physician query processes.
• Experience working with ICD-10-CM/PCS documentation requirements.
• Knowledge of inpatient reimbursement methodologies including MS-DRG and APR-DRG systems.
• Knowledge of documentation regulations, compliant query practices, and coding guidelines.
• Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and Electronic Medical Records.

Responsibilities

• Provides expert level review of clinical records within 24-48 hours of admission; reviews clinical documentation to ensure consistency and alignment with evidence-based guidelines.
• Conducts clear communication to providers to reinforce evidence-based guidelines are being followed.
• Effectively tracks productivity to allow for accurate/timely reporting of leading indicators and future impact analyses.
• Provides expert level leadership for overall improvement in clinical documentation and articulates recommendations and rationale.
• Provides educational opportunities for physicians and other health care team members.
• Participates in education strategies resulting in improved clinical documentation.

Skills

Communication with physicians

CDI expertise

Inpatient chart reviews

Query processes

ICD-10-CM/PCS knowledge

MS-DRG/APR-DRG knowledge

Windows proficiency

Education

Undergraduate degree or equivalent experience

RN license or Medical School Graduate

Tools

Microsoft Word

Excel

Electronic Medical Records

Job description

UnitedHealth Group is seeking a clinical documentation integrity (CDI) specialist to review medical records within 24-48 hours of admission and collaborate with physicians to ensure alignment with evidence-based guidelines.

The role supports remote work from anywhere in the U.S., with a comprehensive benefits package and pathways for education and career growth.

Required qualifications include nursing or medical degree, CDI experience, and knowledge of ICD-10-CM/PCS and MS-DRG systems.