Clinical Documentation Integrity Specialist - Remote
About The Position
Optum Insight is seeking a Clinical Documentation Integrity Specialist to review inpatient clinical records and improve the accuracy and completeness of clinical documentation. The role reviews records within 24–48 hours of admission, identifies gaps requiring clarification for accurate code assignment, and helps ensure documentation reflects patients’ severity of condition and acuity of care. The specialist communicates with providers, offers recommendations and feedback, and documents clarification activity in CDI software. The position works remotely from anywhere within the U.S., but requires Pacific Time Zone business hours Monday through Friday. Remote employees must comply with UnitedHealth Group’s Telecommuter Policy.
Requirements
- Qualify through one of the following: be a medical graduate (MD or MBBS), or be a Registered Nurse with an active, unrestricted U.S. RN license and at least 5 years of acute care hospital experience.
- Hold a current CCDS, CDIP, or CCS certification, or be willing and able to obtain one within 1 year of hire.
- At least 2 years of experience working 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.
Nice To Haves
- BSN degree for candidates who are RNs.
- At least 3 years of experience working in an acute care hospital.
- CAC experience (Computer Assisted Coding).
Responsibilities
- Review inpatient clinical records within 24–48 hours of admission and identify documentation gaps requiring clarification for accurate code assignment.
- Conduct daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.
- Provide leadership for improvement in clinical documentation through proficient review and assessment, and articulate 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 about documentation improvement opportunities and successes.
- Use CDI software effectively to document verbal, written, and electronic clarification activity.
- Develop a reciprocal working relationship with HIM Coding Professionals.
- Engage and consult with the Physician Advisor/VPMA as needed under the escalation process to resolve provider issues related to clarifications and participation in the clinical documentation improvement process.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
