Job Title: Clinical Document Improvement Specialist (CDS)
Company: Optum (a UnitedHealth Group company)
Location: Greenbrae, California, USA (Hybrid – 25% onsite)
Company Overview:
Parent Organization: UnitedHealth Group
Mission: To help people live healthier lives and make the health system work better for everyone
Focus Areas: Care delivery, pharmacy benefits, data integration, health equity
Work Culture: Guided by diversity, inclusion, career development, and innovation
Position Summary:
The Clinical Document Improvement Specialist (CDS) provides expert-level review of inpatient medical records to ensure accuracy, completeness, and specificity in documentation. This role supports accurate coding, revenue integrity, and quality reporting. The CDS will collaborate with physicians and healthcare teams to improve documentation practices using the Optum® CDI 3D technology.
Work Environment:
Setting: Inpatient hospital setting
Remote Work: Hybrid – 25% onsite required
Location: Must reside within a commutable distance to Greenbrae, CA
Patient Interaction: No direct patient care responsibilities
Primary Responsibilities:
Review inpatient records within 24–48 hours of admission
Identify documentation gaps and provide clarifications to providers
Communicate with providers to improve specificity and completeness
Conduct rounding with physicians and provide documentation support
Lead physician education on documentation best practices
Utilize Optum CDI 3D technology for documentation and query tracking
Collaborate with HIM Coders, Care Coordination, and Quality teams
Engage Physician Advisors or VPMA for escalation, if needed
Maintain compliance with all CDI and documentation guidelines
Required Qualifications:
5+ years of acute care hospital RN experience OR Medical graduate with 1+ year CDI experience
1+ year of clinical documentation improvement experience in an inpatient setting
Proficiency in Microsoft Office and Electronic Medical Records (EMR)
Experience collaborating with physicians
Must live within commuting distance to Greenbrae, CA
Preferred Qualifications:
Education: BSN (if RN)
Certifications: CCDS, CDIP, or CCS
Technology: Experience with Computer-Assisted Coding (CAC)
Technology Used:
Optum® CDI 3D
Microsoft Office Suite
Electronic Medical Records (EMR)
Compensation & Benefits:
Salary Range: $71,600 – $140,600 annually (based on experience, location, etc.)
Benefits:
Comprehensive health insurance
401(k) with company contribution
Equity stock purchase plan
Incentive and recognition programs
Paid time off and more
Compliance: Must pass a drug test prior to employment
Workplace Values & Commitments:
Focus on health equity and environmental impact
Commitment to diversity, equity, and inclusion (DEI)
EEO employer — welcomes applicants regardless of race, gender, identity, age, disability, or veteran status
Drug-free workplace
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