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Clinical Documentation Specialist
2 months ago
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities.
Job SummaryThe Clinical Documentation Specialist will be responsible for providing CDI program oversight and day-to-day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal of the CDI oversight and practice is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.
Key Responsibilities- Provides expert-level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided.
- Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.
- Provides expert-level leadership for overall improvement in clinical documentation by providing proficient-level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations.
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality.
- Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination.
- Provides face-to-face educational opportunities with physicians on a regular basis.
- Provides complete follow-through on all requests for clarification or recommendations for improvement.
- Leads the development and execution of physician education strategies resulting in improved clinical documentation.
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes.
- Ensures effective utilization of Optum CDI 3D Technology to document all clarification activity.
- Utilizes only the Optum360 approved clarification forms.
- Proactively develops a reciprocal relationship with the HIM Coding Professionals.
- Coordinates and conducts regular meetings with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI.
- Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process.
- Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities.
- 5+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP).
- 1+ years experience as a clinical documentation integrity specialist.
- Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records.
- Experience communicating & working closely with Physicians.
