Clinical Documentation Improvement Specialist

UnitedHealth Group • Phoenix, AZ

4d • $60,200 - $107,400 • Remote

About The Position

The Clinical Documentation Improvement Specialist (CDS) provides CDI program oversight and implements processes for concurrent review of inpatient medical-record documentation for Optum 360 clients. The role assesses the technical accuracy, specificity, and completeness of provider documentation to ensure it explicitly identifies clinical findings and conditions present at the time of service. The CDS reviews clinical information to improve documentation so it accurately and comprehensively reflects patient treatment, decisions, and diagnoses. The specialist applies clinical expertise, CDI practices, and facility-specific tools in alignment with Optum 360’s standards, goals, and values, and uses Optum CDI 3D technology to support data quality, accurate representation of care, and revenue integrity. The position may be performed remotely from anywhere within the United States, subject to UnitedHealth Group’s Telecommuter Policy.

Requirements

• At least 3 years of acute-care hospital clinical RN experience, or medical graduate education with CDI experience.
• At least 2 years of experience in clinical medicine, pathophysiology, and pharmacology.
• At least 1 year of experience in ICD-10 coding, coding conventions, and guidelines.
• Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, PowerPoint, and electronic medical records.

Nice To Haves

• CCDS, CDIP, or CCS certification.
• At least 5 years of acute inpatient hospital coding experience with certifications.
• At least 3 years of CDI experience for an acute-care hospital.
• Computer-assisted coding (CAC) experience.

Responsibilities

• Perform concurrent and retrospective chart reviews to improve the overall completeness of clinical documentation.
• Stay current on coding trends and Medicare rules and regulations related to diagnosis coding and CDI.
• Use ICD-10 and related materials to investigate coding issues and produce accurate results.
• Conduct daily follow-up communication with providers about existing clarification requests to obtain needed documentation specificity.
• Provide expert-level leadership for clinical documentation improvement through proficient review and assessment, recommendations, and explanations for those recommendations.
• Communicate with providers at all levels to clarify information and explain documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality.
• Follow through on requests for clarification and recommendations for improvement.
• Use Optum CDI 3D Technology to document clarification activities.
• Use only Optum360-approved clarification forms.
• Develop reciprocal working relationships with HIM Coding Professionals.
• Engage and consult with the Physician Advisor or VPMA, as needed under the escalation process, to resolve provider issues related to clarification responses and participation in CDI.

Benefits

• Comprehensive benefits package, subject to eligibility requirements.
• Incentive and recognition programs.
• Equity stock purchase plan.
• 401(k) contribution, subject to eligibility requirements.
• Career development opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed