Clinical Documentation Integrity Specialist Hybrid

About the role

The Clinical Documentation Integrity Specialist - (CDS) is responsible for providing CDI program oversight and day-to-day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, ensuring it explicitly identifies all clinical findings and conditions present at the time of service.

Responsibilities

• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided.
• Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.
• Provides 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 communicates 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.
• Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination.
• Provides face-to-face educational opportunities with physicians on a regular basis.
• Provides complete follow through on all requests for clarification or recommendations for improvement.
• Led the development and execution of physician education strategies resulting in improved clinical documentation.
• Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes.
• Ensures effective utilization of Optum™ CDI 3D Technology to document all clarification activity.
• Utilizes only the Optum360 approved clarification forms.
• Proactively develops a reciprocal relationship with the HIM Coding Professionals.
• Coordinates and conducts regular meetings with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI.
• Engages and consults 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.
• Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities.

Qualifications

• 3+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
• Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records
• Experience communicating & working closely with Physicians

Preferred Qualifications

• BSN degree if a RN
• CCDS, CDIP or CCS certification
• Experience in Clinical Documentation Integrity
• CAC experience (Computer Assistant Coding)

Pay and Benefits

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.