Clinical Documentation Integrity Specialist - Remote

About the role

UnitedHealth Group's Optum Insight is hiring a Clinical Documentation Integrity Specialist to work remotely from anywhere in the U.S. The role reviews inpatient clinical records to ensure they accurately reflect the severity of the condition and the acuity of care, so that codes are assigned correctly. It requires working Pacific Time Zone business hours (Monday to Friday).

Key responsibilities

• Review inpatient clinical records within 24-48 hours of admission and identify gaps that need clarification for accurate code assignment.
• Follow up daily with providers to obtain the documentation specificity needed.
• Lead improvements in clinical documentation by assessing records and recommending changes with clear rationale.
• Communicate with providers at all levels about documentation requirements for diagnoses based on illness severity and risk of mortality.
• Give timely feedback to providers on documentation opportunities for improvement and successes.
• Use CDI software to record all verbal, written and electronic clarifications.
• Build a reciprocal relationship with the hospital coding professionals and consult the Physician Advisor / VPMA when escalation is needed.

Required profile

• Medical graduate (MD or MBBS), or Registered Nurse with an active, unrestricted US license and 5+ years of acute care hospital experience.
• Current CCDS, CDIP or CCS certification, or willingness to obtain one within 1 year or to be hired.
• 2+ years of experience as a Clinical Documentation Improvement Specialist in an acute care hospital.
• Advanced knowledge of clinical medicine, pathophysiology and pharmacology.
• Ability to work Pacific Time Zone hours Monday to Friday, regardless of residence.
• Preferred: BSN degree, 3+ years of acute care experience, CAC experience, and experience working closely with physicians.

Required skills

• Intermediate proficiency with a PC in a Windows environment, including Microsoft Word, Excel, PowerPoint and electronic medical records.

What we offer

• Salary of $60,200 to $107,400 annually for full-time employment, depending on experience, education and certifications.
• Comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (subject to eligibility).
• Remote work flexibility and development opportunities within the organization.