Clinical Documentation Specialist
1 day ago
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, directly impacting patient care and revenue integrity.
Key Responsibilities:- Conduct expert-level reviews of inpatient clinical records within 24-48 hours of admission, identifying gaps in documentation that require clarification for accurate code assignment.
- Communicate daily with providers to clarify information and document requirements for appropriate diagnoses based on severity of illness and risk of mortality.
- Lead the development and execution of physician education strategies to improve clinical documentation, ensuring effective utilization of Optum CDI 3D Technology.
- Collaborate with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates, and discuss coding and CDI-related questions.
- Engage with Care Coordination and Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities.
- 5+ years of acute care hospital clinical RN experience or Medical Graduate with CDI experience and CDI certification (CCDS, CDIP).
- 1+ year 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.
- BSN degree if a RN.
- CAC experience (Computer Assistant 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 offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution. If you're passionate about improving health outcomes and making a difference in the lives of others, we encourage you to apply for this exciting opportunity.
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