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Clinical Documentation Integrity Specialist
Clinical Documentation Integrity SpecialistUnitedHealth Group • East Saint Louis, IL, US
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Clinical Documentation Integrity Specialist

Clinical Documentation Integrity Specialist

UnitedHealth Group • East Saint Louis, IL, US
13 days ago
Job type
  • Full-time
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 of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal of the CDS practice is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, ensuring that the documentation explicitly identifies all clinical findings and conditions present at the time of service.

This position collaborates with providers and other healthcare team members to improve accurate, comprehensive documentation reflecting the clinical treatment, decisions, and diagnoses. The CDS utilizes clinical expertise, clinical documentation improvement practices, and facility-specific tools for best practices and compliance with Optum 360's standards and values.

The CDS will utilize the Optum CDI 3D technology to help hospitals improve data quality, accurately reflect care quality, and ensure revenue integrity.

Our three-dimensional approach to CDI technology, combined with best-practice adoption and change management support, helps hospitals enhance CDI efficiency and effectiveness.

  • Increase in identification of cases with CDI opportunities, with automated review of 100% of records
  • Improved tracking, transparency, and reporting related to CDI impact, revenue capture, trending, and compliance
  • Easing the transition to ICD-10 by improving documentation specificity and completeness, leading to more accurate coding

This position does not involve patient care duties, direct patient interactions, or roles related to patient care.

If located in the St. Louis region, you will have the flexibility to telecommute, as well as attend on-site meetings and education sessions to tackle some challenging tasks.

Primary Responsibilities :

  • Provides expert review of inpatient clinical records within 24-48 hours of admission; identifies documentation gaps needing clarification for accurate coding and reflects severity and acuity
  • Conducts daily follow-up with providers to clarify documentation as needed
  • Leads clinical documentation improvement efforts through proficient review, assessment, and clear communication of recommendations
  • Communicates with providers at all levels to clarify information and documentation requirements
  • Performs rounding with physicians and provides Working DRG lists to Care Coordination
  • Offers face-to-face educational opportunities with physicians daily
  • Follows up on clarification requests and improvement recommendations
  • Develops and executes physician education strategies for documentation improvement
  • Provides timely feedback on documentation opportunities and successes
  • Utilizes Optum CDI 3D Technology effectively for verbal, written, and electronic clarification documentation
  • Uses only approved clarification forms
  • Develops reciprocal relationships with HIM Coding Professionals
  • Coordinates meetings with HIM Coding to reconcile DRGs, monitor query rates, and discuss coding / CDI questions
  • Engages with Physician Advisor / VPMA to resolve provider issues related to clarifications and documentation improvement
  • Collaborates with Care Coordination and Quality Management teams to identify and lead documentation improvement opportunities
  • Employees are recognized for their performance in a challenging environment that offers clear success pathways and development opportunities.

    Required Qualifications :

  • 3+ years of acute care hospital RN experience or CDI experience as a Foreign Medical Graduate
  • Experience in Clinical Documentation Improvement
  • Proficiency in Windows-based PC applications, including Word, Excel, PowerPoint, and Electronic Medical Records
  • Experience working closely with physicians
  • Full COVID-19 vaccination is required, with adherence to booster requirements as per state regulations. Proof of vaccination and boosters will be obtained prior to employment in compliance with all regulations.
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    Clinical Documentation Specialist • East Saint Louis, IL, US

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