<span>Clinical Documentation Improvement Specialist - San Luis Obispo CA</span>

$70,200 - $137,800/Yr

Optum - San Luis Obispo, CA

Full-time - Mid Level

Onsite - San Luis Obispo, CA

5,001-10,000 employees

Insurance Carriers and Related Activities

About the position

The Clinical Documentation Improvement Specialist (CDS) is responsible for overseeing and implementing clinical documentation improvement processes for Optum 360 clients. This role focuses on the concurrent review of clinical documentation in inpatient medical records to ensure accuracy, specificity, and completeness. The CDS collaborates with healthcare providers to enhance documentation quality, which directly impacts health outcomes and revenue integrity. Utilizing advanced technology and best practices, the CDS aims to improve documentation efficiency and effectiveness while supporting the transition to ICD-10 coding standards.

Responsibilities

• 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.
• 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 articulating recommendations for improvement and the rationale for those recommendations.
• Actively communicates with providers at all levels to clarify information and communicate documentation requirements for appropriate diagnoses.
• Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination.
• Provides face-to-face educational opportunities with physicians on a regular basis.
• Ensures 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.
• Utilizes Optum® CDI 3D Technology to document all clarification activity and uses only approved clarification forms.
• Coordinates and conducts regular meetings with HIM Coding Professionals to monitor retrospective query rates and discuss questions related to Coding and CDI.
• Engages with Physician Advisor / VPMA when needed to resolve provider issues regarding clarifications and participation in the clinical documentation improvement process.
• Actively engages with Care Coordination and Quality Management teams to evaluate and spearhead clinical documentation improvement opportunities.

Requirements

• A Medical Graduate (MD or MBBS) with CDI Experience or a Registered Nurse (RN) with an active, unrestricted RN License in CA and at least 5+ years of clinical experience.
• Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point, and Electronic Medical Records.
• Experience communicating and working closely with Physicians.
• Must live in the San Luis Obispo CA regional area and be willing to work onsite full time (Monday - Friday).

Nice-to-haves

• BSN degree if a RN
• CCDS, CDIP or CCS certification
• Experience in Clinical Documentation Improvement
• CAC experience (Computer Assistant Coding)

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution