Clinical Documentation Improvement Specialist

About the role

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

This position offers the flexibility to work remotely from anywhere within the U.S.

Responsibilities

• Perform DRG validation reviews and confirm appropriate diagnosis related group (DRG) assignments.
• Maintain current working knowledge of ICD-10 coding principles and CMS regulations.
• Investigate, review, and provide clinical and/or coding expertise and judgement in the application of medical and reimbursement policies within the claim adjudication process through medical records review.
• Serve as a Subject Matter Expert (SME), performing medical record reviews to include quality audits, validation of accuracy and completeness of all coding elements, and medical necessity reviews.
• Provide guidance related to Payment Integrity initiatives including concept and cost avoidance development.
• Serve cross-functionally with Medical Directors, Utilization Management, and other internal teams to assist in identification of overpayments.
• Act as SME for all Payment Integrity functions including Retrospective Data Mining and Pre-Payment Cost Avoidance.
• Identify trends and patterns with overall program