Remote Clinical Documentation Improvement Specialist

Optum; United States; Remote; USD 73,000 - 130,000; Full time

Job summary

Optum is seeking a Clinical Documentation Improvement (CDI) professional to review inpatient records promptly and guide physicians toward compliant documentation. The role supports education and process improvement while working remotely across the United States.

You will collaborate with physicians and care teams, manage education initiatives, and coordinate with Medical Directors to drive sustained documentation quality and compliance with ICD-10-CM/PCS and DRG guidelines.

Qualifications

• Undergraduate degree or equivalent experience.
• Current RN License or Medical School Graduate.
• Experience communicating with physicians and performing inpatient chart reviews.
• Knowledge of ICD-10-CM/PCS and reimbursement methodologies.
• Proficiency with Microsoft Word, Excel, and EMR systems.

Responsibilities

• Provides expert level review of clinical records within 24-48 hours of admission.
• Communicates with providers to reinforce evidence-based guidelines.
• Tracks productivity for timely reporting and impact analyses.
• Leads improvement recommendations for clinical documentation with rationale.
• Provides educational opportunities for physicians and healthcare team members.
• Engages with Care Coordination and Quality Management to drive opportunities.

Skills

Communication with physicians

Concurrent inpatient chart reviews

ICD-10-CM/PCS documentation

MS-DRG/APR-DRG knowledge

EMR systems

Microsoft Word/Excel

Windows PC proficiency

Education

Undergraduate degree or equivalent

RN license

MD/DO degree

Tools

EMR systems

Job description

Optum is seeking a Clinical Documentation Improvement (CDI) professional to review inpatient records promptly and guide physicians toward compliant documentation. The role supports education and process improvement while working remotely across the United States.

You will collaborate with physicians and care teams, manage education initiatives, and coordinate with Medical Directors to drive sustained documentation quality and compliance with ICD-10-CM/PCS and DRG guidelines.