Job Description

Position Location: St. Louis, Missouri (Need to be onsite for meetings) The Clinical Document Integrity Specialist (CDS) is responsible for day-to-day CDI implementation related to the concurrent review of clinical documentation in inpatient medical records for Optum 360 clients. The goal is to assess the accuracy, specificity, and completeness of provider documentation, ensuring all clinical findings and conditions are explicitly identified. This role collaborates with healthcare providers and team members to improve documentation quality, reflecting clinical treatment, decisions, and diagnoses. The CDS utilizes clinical expertise, documentation improvement practices, and facility-specific tools to ensure compliance with Optum 360’s standards and values. The position involves using the Optum CDI 3D technology to enhance data quality, reflect care quality, and maintain revenue integrity. Our three-dimensional CDI approach, combined with best practices and change management, aims to improve CDI efficiency and effectiveness. Key benefits include: Increased identification of CDI opportunities through automated record review Enhanced tracking, transparency, and reporting on CDI impact, revenue, and compliance Smoother ICD-10 transition by improving documentation specificity and completeness This role does not involve direct patient care or interaction. Remote work flexibility is available for those in the St. Louis region, with on-site meetings and education sessions as needed. Primary Responsibilities: Review inpatient records within 24-48 hours of admission, identifying documentation gaps for accurate coding and severity reflection Follow up with providers to clarify documentation needs Lead clinical documentation improvement efforts, providing assessments and recommendations Communicate with providers at all levels to clarify diagnoses and documentation requirements Conduct rounding with physicians and provide DRG lists to Care Coordination Offer face-to-face educational sessions with physicians Follow through on clarification requests and improvement suggestions Develop and implement physician education strategies for documentation enhancement Provide feedback to providers on documentation opportunities Utilize Optum CDI 3D technology to document all clarification activities Use approved clarification forms exclusively Build collaborative relationships with HIM coding professionals, reconciling DRGs and monitoring query rates Engage with Physician Advisor/VPMA as needed to resolve provider issues Collaborate with Care Coordination and Quality teams to identify and lead documentation improvement initiatives We recognize performance and offer a challenging environment with clear success pathways, development opportunities, and recognition. Required Qualifications: 3+ years of acute care hospital RN experience or CDI experience as a Foreign Medical Graduate Experience in Clinical Documentation Improvement Proficiency with Windows-based PC applications, including MS Word, Excel, PowerPoint, and Electronic Medical Records Experience working closely with physicians Full COVID-19 vaccination is required, including boosters if mandated by state regulations #J-18808-Ljbffr UnitedHealth Group

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