Remote Clinical Documentation Improvement Specialist

Optum; Los Alamitos (CA); Remote; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

Equity stock purchase

401k contribution

Job summary

Optum is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient records and guide physicians toward evidence-based coding in a remote role across the U.S. The position emphasizes collaboration with Care and Quality teams and requires strong communication with physicians.

You'll work from anywhere in the U.S., with competitive compensation and benefits. RN or MD candidates with CDI experience are encouraged to apply.

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 and working closely with Physicians.
• Experience performing concurrent inpatient chart reviews and physician query processes.
• Experience with ICD-10-CM/PCS documentation requirements.
• Knowledge of inpatient reimbursement methodologies including MS-DRG and APR-DRG systems.
• Proficiency with Windows, 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 with guidelines.
• Conducts clear communication to providers to reinforce evidence-based guidelines.
• Tracks productivity for accurate reporting of indicators and analyses.
• Leads improvement in clinical documentation with recommendations and rationale.
• Provides educational opportunities for physicians and health care team members.
• Completes follow through on requests for clarification or recommendations.
• Participates in education strategy development for improved documentation.
• Offers timely feedback to providers on opportunities for improvement.
• Engages with Medical Director and leadership to resolve clarifications as needed.
• Collaborates with Care Coordination and Quality Management to drive CDI opportunities.
• Works with less structured, complex issues and serves as a resource to others.

Skills

Physician communication

Concurrent chart reviews

ICD-10-CM/PCS

MS-DRG knowledge

Documentation guidelines

Windows proficiency

Education

Undergraduate degree or equivalent

RN license

Medical School Graduate

Tools

MS Word

MS Excel

EMR systems

Job description

Optum is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient records and guide physicians toward evidence-based coding in a remote role across the U.S. The position emphasizes collaboration with Care and Quality teams and requires strong communication with physicians.

You'll work from anywhere in the U.S., with competitive compensation and benefits. RN or MD candidates with CDI experience are encouraged to apply.