Senior Clinical Documentation Improvement Specialist

Jobtome; Buena Park (CA); On-site; USD 73,000 - 130,000; Full time

Benefits offered by this job

Comprehensive benefits

Equity stock purchase

401k contribution

Job summary

UnitedHealth Group seeks a CDI-focused clinician to review inpatient records and drive documentation improvements. You will work closely with physicians and care teams to ensure accurate coding and severity reflection.

The role requires clinical expertise, CDI experience, and strong communication with providers. A comprehensive benefits package and professional development opportunities are offered.

Qualifications

• Associate's degree required.
• 5+ years of acute care hospital RN experience OR Medical Graduate with CDI experience.
• Advanced knowledge in clinical medicine, pathophysiology, and pharmacology.
• Strong communication skills with physicians and care teams.

Responsibilities

• Review inpatient clinical records within 24–48 hours of admit and identify gaps for accurate code assignment.
• Follow up daily with providers to obtain needed documentation specificity.
• Clarify information with providers to ensure diagnoses reflect severity and risk of mortality.
• Lead education strategies with physicians to improve clinical documentation.
• Coordinate with HIM Coding Professionals and CDI teams to reconsolidate DRGs and monitor queries.

Skills

RN experience

PC proficiency

Clinical knowledge

Physician communication

Education

Associate's degree

Tools

Electronic Medical Records (EMR)

Windows Office (Word/Excel/PowerPoint)

Job description

UnitedHealth Group seeks a CDI-focused clinician to review inpatient records and drive documentation improvements. You will work closely with physicians and care teams to ensure accurate coding and severity reflection.

The role requires clinical expertise, CDI experience, and strong communication with providers. A comprehensive benefits package and professional development opportunities are offered.