Clinical Documentation Improvement Specialist - Remote
About The Position
This role provides expert-level review of clinical records within 24–48 hours of admission to ensure documentation is consistent with evidence-based guidelines. The specialist communicates with providers about documentation and guideline adherence, tracks productivity and reporting indicators, and recommends improvements with clear rationale. The role also supports education for physicians and other healthcare team members, follows through on clarification requests, and provides timely feedback on documentation opportunities and successes. The specialist collaborates with Medical Directors and leadership through established escalation processes, and works with Care Coordination and Quality Management teams to identify and advance clinical documentation improvement opportunities. Work is generally self-directed and may involve complex, less structured issues; the specialist also serves as a resource to others. The position can be performed remotely from anywhere within the United States, subject to the company’s Telecommuter Policy.
Requirements
- Undergraduate degree or equivalent experience.
- Current RN license or medical school graduate status.
- For RNs: at least 3 years of acute inpatient CDI experience.
- For medical school graduates: at least 2 years of acute inpatient CDI experience.
- Experience communicating and working closely with physicians.
- Experience conducting concurrent inpatient chart reviews and physician query processes.
- Experience with ICD-10-CM/PCS documentation requirements.
- Knowledge of inpatient reimbursement methodologies, including MS-DRG and APR-DRG systems.
- Knowledge of documentation regulations, compliant query practices, and coding guidelines.
- Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and Electronic Medical Records.
- Remote employees must adhere to UnitedHealth Group’s Telecommuter Policy.
- Candidates must pass a drug test before beginning employment.
Nice To Haves
- For RNs, a BSN degree.
- Current CCDS, CDIP, or CCS certification.
- Excellent verbal and written communication skills and solid organizational skills.
Responsibilities
- Review clinical records within 24–48 hours of admission and assess documentation for consistency with evidence-based guidelines.
- Communicate with providers to reinforce adherence to evidence-based guidelines.
- Track productivity to support accurate and timely reporting of leading indicators and future impact analyses.
- Lead improvement in clinical documentation through proficient review, assessment, and recommendations with supporting rationale.
- Provide educational opportunities for physicians and other healthcare team members.
- Follow through on requests for clarification and recommendations for improvement.
- Participate in developing and executing education strategies to improve clinical documentation.
- Provide timely feedback to providers about documentation opportunities for improvement and successes.
- Consult with Medical Directors and leadership, as needed and according to the escalation process, to resolve issues involving clarifications and participation in the CDI process.
- Engage with Care Coordination and Quality Management teams to evaluate and advance clinical documentation improvement opportunities.
- Serve as a resource to others and address complex, less structured issues.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs, subject to eligibility requirements.
- Equity stock purchase, subject to eligibility requirements.
- 401(k) contribution, subject to eligibility requirements.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
