Location: Long Beach, California, United States
Job Category: Medical and Clinical Operations
Requisition Number: 2338818
Employment Type: Full-Time
Work Setting: Onsite at Client Hospital
Overview
Optum, part of UnitedHealth Group, is a global healthcare services organization focused on improving health outcomes through technology-enabled solutions, revenue cycle optimization, and clinical excellence. Within Optum 360, the Clinical Documentation Integrity (CDI) program supports hospitals in enhancing documentation accuracy, coding specificity, regulatory compliance, and revenue integrity.
The Clinical Documentation Integrity Specialist (CDS) plays a critical role in concurrent inpatient medical record review. This position ensures that provider documentation accurately reflects patient severity of illness, risk of mortality, clinical decision-making, and services rendered. This is a non-patient-facing role focused exclusively on documentation improvement and compliance.
This onsite opportunity in Long Beach, California is ideal for experienced acute care nurses or medical graduates with CDI expertise seeking to advance in clinical documentation improvement, revenue cycle management, or health information leadership.
Role Summary
The CDS provides oversight and day-to-day implementation of CDI processes, including real-time review of inpatient medical records within 24–48 hours of admission. The primary objective is to identify documentation gaps and collaborate with physicians and healthcare teams to improve the specificity, completeness, and accuracy of clinical documentation.
Using Optum CDI 3D technology, the specialist ensures that documentation supports appropriate MS-DRG assignment, ICD-10 coding accuracy, quality reporting, and compliance standards. The role contributes directly to improved data integrity, reimbursement accuracy, and clinical transparency.
Key Responsibilities
Perform expert-level concurrent review of inpatient medical records to identify documentation gaps impacting coding accuracy and severity capture.
Initiate and follow up on physician queries to obtain clarification and ensure appropriate documentation specificity.
Communicate documentation requirements related to severity of illness, risk of mortality, and accurate diagnosis capture.
Conduct daily rounding with unit-based physicians and provide Working DRG lists to Care Coordination teams.
Deliver structured physician education sessions focused on documentation improvement and regulatory compliance.
Ensure proper utilization of Optum CDI 3D technology to track clarification activity and CDI metrics.
Collaborate proactively with Health Information Management (HIM) coding professionals to reconcile DRGs and monitor retrospective query trends.
Coordinate meetings with HIM and coding teams to address coding questions and documentation alignment.
Escalate documentation or participation concerns to Physician Advisors or leadership as required.
Partner with Care Coordination and Quality Management teams to identify ongoing documentation improvement opportunities.
Maintain compliance with Optum 360 clarification standards and approved documentation processes.
Note: This position does not involve direct patient care or bedside responsibilities.
Required Qualifications
Minimum 5+ years of acute care hospital clinical RN experience
OR
Medical Graduate with Clinical Documentation Improvement experience and CDI certification (CCDS or CDIP).
Proficiency in Microsoft Word, Excel, PowerPoint, and Electronic Medical Record systems.
Demonstrated experience collaborating and communicating effectively with physicians.
Must be local to Long Beach, California and willing to work onsite at the client hospital.
Preferred Qualifications
Bachelor of Science in Nursing (BSN), if Registered Nurse.
CCDS, CDIP, or CCS certification.
Prior experience in Clinical Documentation Improvement within an acute care setting.
Experience with Computer-Assisted Coding (CAC) systems.
Compensation and Benefits
The salary range for this full-time role is approximately USD 72,800 to 130,000 annually, depending on experience, education, certifications, and local labor market factors.
The comprehensive benefits package may include medical, dental, and vision coverage, retirement savings plans with employer contributions, incentive and recognition programs, equity stock purchase options, and professional development opportunities. Eligibility requirements apply.
Career Impact
This role offers a strategic opportunity to work at the intersection of clinical care, documentation integrity, healthcare compliance, ICD-10 coding accuracy, and hospital revenue optimization. Professionals in this position contribute directly to improved healthcare data quality, regulatory alignment, and financial sustainability for healthcare institutions.
Gujarat :
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Siliguri |Illinois :
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Appleton | Kenosha | Pleasant Prairie | Portage | Waukesha |United states :
Arizona | Buffalo Grove | Clayton | Downers Grove | fairmont | Georgia | Keene | Michigan | Mt. Pleasant | New Jersy | OH | Piedmont | Salisbury | United States | Whitesboro | Winston-Salem |Georgia :
Atlanta | Augusta | Rome |Maine :
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Frank Scottile Blvd |Missouri :
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Europe | France | Latvia | Lendava | Leuven | Poland | Slovenia | Spain |Finland :
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Istanbul | Turkey |Norway :
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Sheffield |Oxfordshire :
Witney |Ontario :
Richmond Hill | Uxbridge | North York | Mississauga | Australia | Renfrew |Canada :
Canada |Quebec :
Montreal |Brussels :
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Zaventem |South America :
Peru | Argentina |Brazil :
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Greece |North Island :
Auckland |New Zealand :
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Barcelona |Madrid :
Madrid |Cebu Province :
Cebu City |Philippines :
Manila |Croatia :
Croatia |Zagreb :
Zagreb |Estonia :
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Tallinn |Hà Nội :
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Oulu |Southwest Finland (Varsinais-Suomi) :
Turku |Remote Korea :
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