Senior CDI Specialist: Elevate Care Through Documentation

Jobtome; San Marino (CA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits package

401k contribution

Equity stock purchase plan

Job summary

Optum is seeking an experienced Clinical Documentation Improvement (CDI) Specialist to review inpatient records within 24–48 hours of admission, identify documentation gaps, and clarify needs with providers. You will lead education efforts and coordinate with HIM professionals to drive DRG accuracy and care quality.

The role emphasizes collaboration with physicians, leveraging Optum360 tools, and contributing to a robust documentation improvement program across the care continuum.

Qualifications

• Associate degree required.
• 5+ years of acute care hospital RN experience or Medical Graduate with CDI experience.
• Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
• Advanced proficiency communicating and working closely with Physicians.
• Intermediate proficiency with Windows PC, MS Word/Excel/PowerPoint and EMR.

Responsibilities

• Review inpatient clinical records within 24–48 hours of admit to ensure accurate code assignment.
• Identify gaps in documentation needing clarification for appropriate diagnoses.
• Following up with providers to obtain documentation specificity.
• Perform regular rounding with physicians and provide Working DRG lists to Care Coordination.
• Lead physician education strategies to improve clinical documentation.
• Collaborate with HIM Coding Professionals and Physician Advisor as needed.

Skills

Clinical medicine

Pathophysiology

Pharmacology

Physician communication

EMR proficiency

Windows PC skills

Education

Associate's degree

BSN preferred

CDI certifications

Job description

Optum is seeking an experienced Clinical Documentation Improvement (CDI) Specialist to review inpatient records within 24–48 hours of admission, identify documentation gaps, and clarify needs with providers. You will lead education efforts and coordinate with HIM professionals to drive DRG accuracy and care quality.

The role emphasizes collaboration with physicians, leveraging Optum360 tools, and contributing to a robust documentation improvement program across the care continuum.