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Clinical Documentation Specialist

2 months ago


Phoenix, Arizona, United States Optum Full time
Optum Clinical Documentation Integrity Specialist

At Optum, we're dedicated to delivering care and improving health outcomes for millions of people worldwide. As a Clinical Documentation Integrity Specialist, you'll play a critical role in ensuring the accuracy and completeness of clinical documentation, which is essential for delivering high-quality care and driving revenue integrity.

Key Responsibilities:
  • Conduct expert-level reviews of inpatient clinical records to identify gaps in documentation and ensure accuracy and completeness.
  • Collaborate with healthcare teams to clarify information and provide documentation requirements for accurate diagnoses.
  • Develop and execute physician education strategies to improve clinical documentation practices.
  • Utilize Optum's CDI 3D technology to document clarification activity and ensure effective utilization of approved clarification forms.
  • Work closely with HIM Coding Professionals to monitor retrospective query rates and discuss coding and CDI-related questions.
Requirements:
  • 5+ years of acute care hospital clinical RN experience or Medical Graduate with CDI experience and CDI certification (CCDS, CDIP).
  • 1+ years of experience as a clinical documentation integrity specialist.
  • Proficiency in using a PC in a Windows environment, including Microsoft Word, Excel, PowerPoint, and Electronic Medical Records.
  • Experience communicating and working closely with physicians.
Preferred Qualifications:
  • BSN degree if a RN.
  • CAC experience (Computer-Assisted Coding).
  • CCDS, CDIP, or CCS certification.

At Optum, we're committed to creating a diverse and inclusive work environment that values and respects all employees. We believe that everyone deserves the opportunity to live their healthiest life, and we're dedicated to making a positive impact on the communities we serve.