Remote CDI Specialist: Elevate Inpatient Documentation

University of Minnesota School of Nursing; Concord (CA); On-site; USD 60,000 - 107,000; Full time

Job summary

UnitedHealth Group is seeking a Clinical Documentation Improvement Specialist to review inpatient records within 24-48 hours of admission, identify documentation gaps, and drive accuracy across coding and severity of illness. The role requires collaboration with providers and CDI software usage to support documentation improvements.

Candidates should have MD/MBBS or US RN with license, CCDS/CDIP/CCS or willingness to obtain, 2+ years CDI experience in acute care, and strong clinical knowledge,

Qualifications

• MD/MBBS or US RN with active, unrestricted license and 5+ years acute care hospital experience.
• CCDS/CDIP or CCS certification, or willingness to obtain within 1 year.
• 2+ years CDI experience in acute care hospitals.
• Advanced proficiency in medicine, pathophysiology, and pharmacology.
• Proficient PC skills in Word/Excel/PP and EMR.
• Ability to work Pacific Time Zone business hours.

Responsibilities

• Provides expert level review of inpatient records within 24-48 hours of admit to ensure accurate code assignment.
• Communicates with providers to clarify documentation for severity of illness and mortality risk.
• Leads improvements in clinical documentation and recommends enhancements with rationale.
• Engages with physician advisors and HIM Coding Professionals as needed.
• Ensures effective use of CDI software for documenting clarifications.

Skills

Clinical Documentation Improvement

CDI Specialist experience

Advanced clinical knowledge

MS Office proficiency

Communication with physicians

Pacific Time Zone hours compliance

Education

MD/MBBS

RN license (US)

CCDS/CDIP/CCS Certification

BSN degree

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Electronic Medical Records (EMR)

Job description

UnitedHealth Group is seeking a Clinical Documentation Improvement Specialist to review inpatient records within 24-48 hours of admission, identify documentation gaps, and drive accuracy across coding and severity of illness. The role requires collaboration with providers and CDI software usage to support documentation improvements.

Candidates should have MD/MBBS or US RN with license, CCDS/CDIP/CCS or willingness to obtain, 2+ years CDI experience in acute care, and strong clinical knowledge,