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Clinical Documentation Improvement Specialist - Remote at UnitedHealth Group

Clinical Documentation Improvement Specialist - Remote

UnitedHealth Group Houston, TX (Remote) Full-Time

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)

The Clinical Documentation Improvement Specialist (CDI Specialist) is responsible for completing daily concurrent documentation reviews to ensure the consistency and accuracy of physician documentation. The goal of the CDI Specialist’s role is to assess, review, and provide relevant feedback to reinforce physician education. 

This position collaborates with health care team members to ensure consistent, evidence-based clinical guidelines are being followed and reflected accurately in clinical documentation. The CDI Specialist utilizes expertise and clinical documentation improvement practices as well as program-specific tools to ensure best practices and compliance with the mission/philosophy, standards, goals and core values of Optum Health. 

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. 

Primary Responsibilities:

  • Provides expert level review of clinical records within 24-48 hours of admission; reviews clinical documentation to ensure consistency and alignment with evidence-based guidelines 

  • Conducts clear communication to providers to reinforce evidence-based guidelines are being followed

  • Effectively tracks productivity to allow for accurate/timely reporting of leading indicators and future impact analyses

  • Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rationale for the recommendations

  • Provides educational opportunities for physicians and other health care team members 

  • Provides complete follow through on all requests for clarification or recommendations for improvement

  • Participates in the development and execution of education strategies resulting in improved clinical documentation

  • Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes

  • Engages and consults with Medical Director/leadership when needed, per the escalation process, to resolve issues regarding answering clarifications and participation in the clinical documentation improvement process

  • Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Current RN License or Medical School Graduate

  • For RN: 3+ years CDI experience 

  • For Medical School Graduates: 2+ years of CDI experience 

  • Experience communicating & working closely with Physicians

  • Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and Electronic Medical Records 

Preferred Qualifications:

  • If RN, BSN degree

  • Current certification as a CCDS, CDIP or CCS

  • 5+ years CDI experience 

  • Excellent verbal and written skills including solid organizational skills

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, New York City, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New York City, or Washington residents is $67,800 to $133,100. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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