Clinical Documentation Specialist
3 weeks ago
The Clinical Documentation Integrity Specialist plays a vital role in ensuring the accuracy and completeness of clinical documentation in the inpatient medical record. This position is responsible for providing CDI program oversight and implementing processes related to the concurrent review of clinical documentation.
The goal of this role is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, ensuring that it explicitly identifies all clinical findings and conditions present at the time of service. This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation.
The Clinical Documentation Integrity Specialist will utilize clinical expertise and CDI practices, as well as facility-specific tools, to ensure compliance with the mission, philosophy, standards, goals, and core values of Optum 360. This position will also utilize Optum's CDI 3D technology to improve data quality and ensure revenue integrity.
Key Responsibilities:- Provides expert-level review of inpatient clinical records within 24-48 hours of admission
- Identifies gaps in clinical documentation that need clarification for accurate code assignment
- Conducts daily follow-up communication with providers regarding existing clarifications
- Provides expert-level leadership for overall improvement in clinical documentation
- Actively communicates with providers to clarify information and document requirements
- 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 daily basis
- Ensures effective utilization of Midas or Optum CDI 3D Technology
- Current RN License with 5+ years of acute care experience or Medical School Graduate with CDI experience
- Experience communicating and working closely with physicians
- Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and Electronic Medical Records (Cerner is preferred)
UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
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