Clinical Documentation Specialist
6 days ago
At Optum, we're dedicated to delivering care and technology to help millions of people live healthier lives. As a Clinical Documentation Improvement Specialist, you'll play a critical role in improving health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best.
Job SummaryThe Clinical Documentation Improvement Specialist is responsible for providing oversight and day-to-day implementation of CDI processes related to the concurrent review of clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal 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.
Key Responsibilities- Provide expert-level review of inpatient clinical records within 24-48 hours of admit, identifying gaps in clinical documentation that need clarification for accurate code assignment.
- Conduct daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.
- Provide expert-level leadership for overall improvement in clinical documentation by providing proficient-level review and assessment, and effectively articulating recommendations for improvement.
- Actively communicate with providers at all levels to clarify information and communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality.
- Perform regular rounding with unit-based physicians and provide Working DRG lists to Care Coordination.
- Provide face-to-face educational opportunities with physicians on a regular basis.
- Provide complete follow-through on all requests for clarification or recommendations for improvement.
- Lead the development and execution of physician education strategies resulting in improved clinical documentation.
- Provide timely feedback to providers regarding clinical documentation opportunities for improvement and successes.
- Ensure effective utilization of Optum CDI 3D Technology to document all clarification activity.
- Utilize only the Optum360-approved clarification forms.
- Proactively develop a reciprocal relationship with the HIM Coding Professionals.
- Coordinate and conduct regular meetings with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates, and discuss questions related to Coding and CDI.
- Engage and consult 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 engage with Care Coordination and the 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+ years of experience as a clinical documentation integrity specialist.
- Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, PowerPoint, and electronic medical records.
- Experience communicating and working closely with physicians.
- Reside in a commutable distance to Greenbrae, CA.
- BSN degree if a RN.
- CCDS, CDIP, or CCS certification.
- CAC experience (Computer-Assisted Coding).
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