Clinical Documentation Specialist

3 weeks ago


San Francisco, California, United States Optum Full time
Optum Clinical Document Integrity Specialist Job Description

The Clinical Document Improvement Specialist is responsible for providing expert-level review of inpatient clinical records, identifying gaps in documentation and ensuring accurate code assignment. This role collaborates with healthcare teams to improve clinical documentation, resulting in comprehensive and accurate patient records.

About the Role:

This position involves reviewing inpatient medical records within 24-48 hours of admission, conducting follow-up communication with providers to clarify documentation, and providing leadership to improve clinical documentation quality.

Key Responsibilities:
  • Expert-level review of inpatient clinical records
  • Daily follow-up communication with providers
  • Leadership for overall improvement in clinical documentation

This role is ideal for a clinical RN with 5+ years of experience or a Medical Graduate with CDI experience and certification (CCDS, CDIP). The salary for this position is estimated at $70,200 - $137,800 per year.



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