Senior Clinical Documentation Improvement Specialist

Jobtome; South Gate (CA); On-site; USD 73,000 - 130,000; Full time

Job summary

Optum, part of UnitedHealth Group, is seeking a CDI-focused RN or Medical Graduate with CDI experience to review inpatient records, clarify documentation, and collaborate with physicians to improve coding accuracy. You will educate providers and coordinate with HIM and Care Coordination teams to drive clinical documentation improvement.

Requires an Associate's degree and 5+ years in acute care RN or CDI roles, with strong clinical knowledge and proficiency with EMR systems.

Qualifications

• Associate's degree required.
• 5+ years of acute care RN or CDI experience.
• Advanced proficiency in clinical medicine, pathophysiology and pharmacology.
• Strong communication with physicians.
• Proficiency with PC applications and EMR.

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit.
• Identify gaps in documentation for accurate code assignment.
• Follow up with providers to obtain documentation specificity.
• Communicate with physicians to clarify diagnoses based on severity.
• Conduct rounds with physicians and provide DRG lists to Care Coordination.
• Educate physicians on documentation improvement strategies.
• Coordinate with HIM Coding Professionals and Physician Advisor as needed.
• Engage Care Coordination and Quality Management to drive CDI opportunities.

Skills

Clinical RN experience

CDI communication with physicians

Advanced clinical knowledge

PC skills (Windows)

Microsoft Word

Microsoft Excel

PowerPoint

Electronic Medical Records

Education

Associate's degree

BSN preferred

CCDS/CDIP/CCS preferred

Tools

EMR systems

Job description

Optum, part of UnitedHealth Group, is seeking a CDI-focused RN or Medical Graduate with CDI experience to review inpatient records, clarify documentation, and collaborate with physicians to improve coding accuracy. You will educate providers and coordinate with HIM and Care Coordination teams to drive clinical documentation improvement.

Requires an Associate's degree and 5+ years in acute care RN or CDI roles, with strong clinical knowledge and proficiency with EMR systems.