Remote Clinical Documentation Improvement Specialist

Stryker Corporation; Concord (CA); On-site; Confidential; Full time

Job summary

UnitedHealth Group, via Optum, is seeking a Clinical Documentation Improvement Specialist to review inpatient records and guide documentation to reflect illness severity and care acuity. This remote role supports providers nationwide with PT-considered hours and collaboration across HIM coding teams.

Requirements include MD/MBBS or US RN license with 5+ years acute care, CDI certification or ability to obtain within a year, 2+ years as a CDI in acute care, and strong clinical pharmacology

Qualifications

• Must have medical degree or RN with US license and 5+ years acute care hospital experience

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit and ensure documentation reflects severity and acuity
• Follow up with providers daily to obtain clearer documentation
• Lead CDI improvement efforts with recommendations and rationale
• Communicate with providers to clarify diagnoses based on severity and risk of mortality
• Provide timely feedback on documentation opportunities and successes
• Ensure effective use of CDI software for documentation
• Develop reciprocal relationship with HIM Coding Professionals
• Consult Physician Advisor as needed to resolve clarification issues

Skills

CDI Specialist

Clinical medicine

Pathophysiology

Pharmacology

EMR software

MS Office

Communication with physicians

Education

MD or MBBS

RN with US license

CDO/CDI certification (CCD S/CDIP/CCS)

Tools

EMR systems

Windows PC proficiency

Job description

UnitedHealth Group, via Optum, is seeking a Clinical Documentation Improvement Specialist to review inpatient records and guide documentation to reflect illness severity and care acuity. This remote role supports providers nationwide with PT-considered hours and collaboration across HIM coding teams.

Requirements include MD/MBBS or US RN license with 5+ years acute care, CDI certification or ability to obtain within a year, 2+ years as a CDI in acute care, and strong clinical pharmacology