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Clinical Documentation Integrity Specialist – San Francisco, Ca

5+ years
Not Disclosed
10 Dec. 5, 2024
Job Description
Job Type: Full Time Education: B.Sc./M.Sc./B.Pharm/M.Pharm/Life science Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

Here is a summary of the Clinical Document Improvement Specialist (CDS) position at Optum:


About Optum

Optum is a global healthcare organization focused on delivering care with the help of technology to improve health outcomes and connect people to the necessary resources. The company emphasizes diversity, inclusion, and career development, aiming to make a positive impact on communities globally.


Role Overview

The Clinical Document Improvement Specialist (CDS) is responsible for overseeing and implementing processes related to clinical documentation improvement (CDI) for inpatient medical records. The main goal is to ensure that documentation accurately reflects the severity of conditions, acuity of care provided, and diagnoses, in compliance with industry standards.


Key Responsibilities

  • Documentation Review: Review inpatient clinical records within 24-48 hours of admit to identify gaps in documentation for accurate coding.
  • Provider Communication: Actively communicate with physicians to clarify and obtain required documentation for accurate diagnoses and severity of illness.
  • Education & Leadership: Lead educational initiatives with physicians to improve documentation practices. Provide feedback on documentation improvement opportunities and successes.
  • Collaboration: Work closely with Health Information Management (HIM) coding professionals, Care Coordination, Quality Management teams, and Physician Advisors to improve CDI outcomes.
  • Technology Use: Utilize Optum® CDI 3D Technology for improving data quality and ensuring accurate revenue capture. Ensure proper use of approved clarification forms.
  • Clarification Follow-up: Ensure thorough follow-through on all requests for clarification and recommendations for improvement in clinical documentation.

Required Qualifications

  • Experience:
    • 5+ years of acute care hospital clinical RN experience, or a Medical Graduate with CDI experience and CDI certification (CCDS, CDIP).
    • 1+ year of experience as a clinical documentation integrity specialist.
  • Skills: Proficiency in Microsoft Word, Excel, PowerPoint, Electronic Medical Records, and communication with physicians.
  • Certifications: CCDS, CDIP, or CCS certification is preferred but not mandatory.

Preferred Qualifications

  • Education: BSN degree if a registered nurse (RN).
  • Additional Experience: Computer-Assisted Coding (CAC) experience.

Work Environment & Compensation

  • Work Location: Onsite at a client hospital.
  • Salary Range (California Residents): $70,200 to $137,800 annually, based on factors such as location, experience, and certifications.
  • Benefits: Includes a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (subject to eligibility).

About UnitedHealth Group

UnitedHealth Group is committed to advancing health equity and addressing health disparities to improve outcomes for all individuals, particularly those from marginalized communities. The company is an Equal Employment Opportunity/Affirmative Action employer and maintains a drug-free workplace.


This role is integral in enhancing clinical documentation to reflect accurate patient care, thereby improving coding accuracy and ensuring compliance with industry standards.