California Licensed Clinical Document Specialist

Job Summary

To enhance clinical documentation practices, the remote Associate Clinical Document Improvement Specialist will provide oversight and implementation of concurrent reviews of inpatient medical records, collaborating with healthcare providers to ensure accurate and comprehensive documentation that reflects the quality of care provided.

Key responsibilities:

• Conduct expert-level reviews of inpatient clinical records to identify documentation gaps for accurate coding within 24-48 hours of admission
• Engage in daily communication with providers to clarify documentation requirements and provide educational opportunities for improvement
• Utilize Optum CDI 3D Technology to track clarification activities and lead physician education strategies to enhance clinical documentation

Required qualifications:

• 3+ years of acute care hospital clinical RN experience or a Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
• Experience in collaborating closely with physicians
• Proficiency in Microsoft Word, Excel, PowerPoint, and Electronic Medical Records