Senior Clinical Documentation Specialist – CDI Expert

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

Benefits offered by this job

Benefits package

401k contribution

Equity stock purchase

Job summary

UnitedHealth Group in the United States seeks a CDI Specialist to review inpatient records promptly, identify documentation gaps, and ensure accurate coding reflecting illness severity. You will educate physicians and coordinate with care teams to drive continuous improvement.

The role requires an Associate's degree, 5+ years of acute care RN or CDI experience, and strong knowledge of clinical medicine, pharmacology, and EMR systems.

Qualifications

• Associate's degree required; 5+ years acute care RN or CDI experience.
• Advanced level of proficiency in clinical medicine, pathophysiology and pharmacology.
• Advanced proficiency communicating with Physicians and in a clinical team.
• Experience with Windows PC and MS Word, Excel, PowerPoint and EMR systems.

Responsibilities

• Review inpatient clinical records within 24-48 hours of admit and identify documentation gaps.
• Clarify documentation to ensure accurate code assignment reflecting severity and acuity.
• Educate physicians on documentation improvements and DRG considerations.
• Lead CDI education strategies and coordinate with HIM Coding Professionals.

Skills

Clinical expertise

Physician communication

Windows & MS Office

Education

Associate's degree

BSN degree (if an RN)

Tools

Electronic Medical Records

CDI tools (Optum360)

Job description

UnitedHealth Group in the United States seeks a CDI Specialist to review inpatient records promptly, identify documentation gaps, and ensure accurate coding reflecting illness severity. You will educate physicians and coordinate with care teams to drive continuous improvement.

The role requires an Associate's degree, 5+ years of acute care RN or CDI experience, and strong knowledge of clinical medicine, pharmacology, and EMR systems.