Clinical Documentation Improvement Specialist

About This Role

This Clinical Documentation Improvement Specialist (CDI) role provides program oversight and day-to-day CDI implementation processes related to the concurrent review of clinical documentation in inpatient medical records for Optum 360 clients' patients. The specialist assesses the technical accuracy, specificity, and completeness of provider clinical documentation to ensure it explicitly identifies all clinical findings and conditions present at the time of service. This position reviews all clinical information and documentation to make improvements that result in accurate, comprehensive documentation reflecting the clinical treatment, decisions, and diagnoses for the patient.

Responsibilities

• Perform concurrent and retrospective chart reviews for improving the overall completeness of clinical documentation
• Keep abreast of current coding trends and maintain up-to-date knowledge of Medicare rules and regulations regarding diagnosis coding and CDI current trends
• Effectively utilize ICD-10 and related materials to investigate coding issues and produce accurate results
• Conduct daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
• Provide expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rationale for the recommendations
• Actively communicate with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
• Provide complete follow-through on all requests for clarification or recommendations for improvement
• Ensure effective utilization of Optum® CDI 3D Technology to document all clarification activities
• Utilize only the Optum 360 approved clarification forms
• Proactively develop a reciprocal relationship with the HIM Coding Professionals
• Engage and consult with Physician Advisor /VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process

Requirements

• 3+ years of acute care hospital clinical RN experience or Medical Graduate with CDI experience
• 2+ years of experience in clinical medicine, pathophysiology, and pharmacology
• 1+ years of experience in…

About the Company

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The company utilizes Optum™ CDI 3D technology to assist hospitals in improving data quality to accurately reflect the quality of care provided and ensure revenue integrity.