Associate Clinical Documentation Improvement Specialist
About The Position
The Associate Clinical Documentation Improvement Specialist reviews inpatient clinical records and identifies documentation gaps that require clarification to support accurate code assignment and ensure the record reflects the severity of the condition and acuity of care. The role communicates with providers about clarifications and documentation requirements, offers feedback on documentation opportunities and successes, and supports improvement in clinical documentation quality. It also requires effective use of CDI software, collaboration with HIM Coding Professionals, and engagement with a Physician Advisor or VPMA when escalation is needed. This position may be performed remotely from anywhere within the U.S., with work during Pacific Time Zone business hours, Monday through Friday. Telecommuters must comply with UnitedHealth Group’s Telecommuter Policy.
Requirements
- Qualify through one of the following: medical graduate (MD or MBBS), or registered nurse with an active, unrestricted U.S. RN license and at least 5 years of acute care hospital experience.
- Current CCDS, CDIP, or CCS certification, or willingness and ability to obtain one within 1 year of hire.
- At least 2 years of experience as a Clinical Documentation Improvement Specialist in an acute care hospital setting.
- Advanced proficiency in clinical medicine, pathophysiology, and pharmacology.
- Intermediate proficiency using a PC in a Windows environment, including Microsoft Word, Excel, PowerPoint, and electronic medical records.
- Ability to work Pacific Time Zone business hours, Monday through Friday, regardless of remote work base location or residency.
- Experience communicating and working closely with physicians.
- Detail-oriented.
Nice To Haves
- BSN degree for candidates who are registered nurses.
- At least 3 years of experience working in an acute care hospital.
- CAC (Computer Assisted Coding) experience.
Responsibilities
- Review inpatient clinical records within 24–48 hours of admission and identify clinical documentation gaps requiring clarification for accurate code assignment.
- Conduct daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.
- Lead improvement in clinical documentation through proficient review and assessment, and clearly explain recommendations and their rationale.
- Communicate with providers at all levels to clarify information and explain documentation requirements for diagnoses based on severity of illness and risk of mortality.
- Provide timely feedback to providers on clinical documentation opportunities for improvement and successes.
- Use CDI software effectively to document verbal, written, and electronic clarification activity.
- Develop reciprocal working relationships with HIM Coding Professionals.
- Consult with the Physician Advisor or VPMA, as needed and according to the escalation process, to resolve provider issues involving clarifications and participation in the CDI process.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
