Clinical Documentation Improvement Specialist

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.

The Clinical Document Improvement 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 clients' patients. The goal of the CDS oversight and practice is to support the CDI manager function by providing staff oversite, serve as an additional resource as well as perform CDI role function. The CDS assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service. This position collaborates with CDI managers, providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. The CDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals and core values of Optum. This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care. This position is fully remote with the ability to work Monday - Friday 8 AM - 5 PM PST.

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 patient 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 rational 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 Provides face-to-face educational opportunities with physicians on a daily basis Provides complete follow-through on all requests for clarification or recommendations for improvement Leads 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 the Midas Clinical Documentation Improvement Focus Study, documenting all verbal, written, electronic clarification activity Utilizes only the Optum approved forms, whether paper or electronic Proactively develops a reciprocal relationship with the HIM Coding Professionals Coordinate and conduct regular meetings with HIM Coding Professionals to monitor retrospective query rate and address issues Engages and consultations with Physician Advisor 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