Clinical Records Improvement Expert
2 weeks ago
Role Overview: This position is integral to the daily implementation of Clinical Documentation Improvement (CDI) processes, focusing on the concurrent review of clinical documentation within inpatient medical records. The role involves evaluating the accuracy, specificity, and completeness of clinical documentation provided by healthcare professionals, ensuring that all clinical findings and conditions are thoroughly documented at the time of service.
Key Responsibilities:
- Conduct expert-level reviews of inpatient clinical records within a 24-48 hour timeframe post-admission, identifying documentation gaps that require clarification for precise coding and accurate representation of patient severity and care provided.
- Maintain daily communication with healthcare providers to address existing clarifications and secure necessary documentation specificity.
- Lead initiatives for enhancing clinical documentation quality by conducting proficient reviews and assessments, articulating improvement recommendations and their rationale effectively.
- Engage with providers at all levels to clarify documentation requirements related to diagnoses based on illness severity and mortality risk.
- Provide timely feedback to healthcare providers regarding opportunities for documentation enhancement and celebrate successes.
- Utilize CDI software effectively to record all verbal, written, and electronic clarification activities.
- Foster a collaborative relationship with Health Information Management (HIM) Coding Professionals.
- Consult with Physician Advisors or Vice Presidents of Medical Affairs as necessary to resolve provider-related issues concerning documentation clarifications and the CDI process.
Required Qualifications:
- A bachelor's degree or equivalent experience.
- A minimum of 7 years of clinical RN experience in an acute care hospital or equivalent experience as a Foreign Medical Graduate with CDI expertise.
- Proven experience in Clinical Documentation Improvement.
- Strong communication skills and experience collaborating closely with physicians.
- Proficiency in using a PC in a Windows environment, including Microsoft Word, Excel, PowerPoint, and Electronic Medical Records.
- A BSN degree or equivalent.
- CCDS, CDIP, or CCS certification.
- Experience with Optum 360 e-CAC.
- Familiarity with Epic systems.
Commitment to Diversity: At Optum, we are dedicated to fostering a diverse and inclusive workplace. We believe that everyone, regardless of race, gender, sexuality, age, location, or income, deserves the opportunity to live their healthiest life. We are committed to addressing health disparities and improving health outcomes for all.
Optum is an Equal Employment Opportunity/Affirmative Action employer. 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.
Optum is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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