Clinical Documentation Integrity - Specialist Location: Eden Prairie, MN, United States Job Description: Requisition number: 2361853 Job category: Medical & Clinical Operations Primary location: Eden Prairie, MN Overtime status: Exempt Travel: No 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. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. This position follows a hybrid schedule with  four in-office days per week. Primary Responsibilities: - Perform concurrent and retrospective chart reviews for improving the overall completeness of clinical documentation - Keep abreast of current coding trends and maintains up to date knowledge of Medicare rules and regulations regarding diagnosis coding and CDI trends - Effectively utilizes ICD-10 and related materials to investigate coding issues and produce accurate results - 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 providing proficient review and assessment, and effectively articulating recommendations for improvement including the rationale for the recommendations - Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality - Provides complete follow through on all requests for clarification or recommendations for improvement - Ensures effective utilization of Technology to document all clarification activity - Collaborates closely with interfacing departments such as Care Coordination and Quality. - Utilizes only the Optum/client approved clarification forms - Proactively develops a reciprocal relationship with the HIM Coding Professionals - Engages and consults with Physician Advisor/CMO when needed, per the hospital defined escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation integrity process 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: - Undergraduate degree or equivalent experience. - 5+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience - Advanced proficiency in clinical medicine, pathophysiology, and pharmacology - Advanced proficiency communicating & working closely with Physicians - Intermediate proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records Preferred Qualifications: - Experience interacting with Providers providing concurrent/chart review - Proven comfortable with technology Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable. 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. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

Role Description The Clinical Documentation Improvement Specialist 2nd Level Reviewer is responsible for conducting in-depth reviews of clinical documentation to ensure compliance with coding guidelines, regulatory requirements, and overall accuracy. This role will collaborate with healthcare providers, coding teams, and other stakeholders to optimize the quality of clinical documentation and support accurate code assignment. Under the direction of CDI leadership, provide clinical documentation and coding education to the CDI team, medical providers, leadership, and other healthcare staff members. The Clinical Documentation Improvement Specialist 2nd Level Reviewer will facilitate improvement in overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation and data analysis. Duties & Responsibilities - Conduct detailed reviews of medical records and physician documentation to ensure accurate, complete, and compliant clinical documentation and code assignment. - Perform quantitative and qualitative reviews of health records, physician queries, and coding practices to ensure documentation accuracy, consistency, and completeness. - Conduct ad hoc and targeted chart reviews, including sepsis, mortality, cardiac, DRG, and site-specific audits, to identify documentation gaps, coding risks, and training opportunities. - Analyze audit results, data trends, and performance metrics to identify root causes, mitigation strategies, and opportunities for process improvement. - Prepare and communicate audit findings, trends, and recommendations to CDI leadership, providers, and staff to support corrective action plans and operational improvements. - Collaborate with coding teams, physicians, nurses, providers, and other stakeholders to clarify documentation and improve clinical documentation integrity practices. - Provide education and training to providers and CDI staff on documentation best practices, coding guidelines, regulatory requirements, and organizational policies and procedures. - Develop, maintain, and deliver educational materials, presentations, assessments, and orientation programs for providers and CDI staff, including new hire onboarding and provider orientation. - Assess and monitor new hire performance throughout onboarding and training, providing feedback and recommendations to CDI leadership. - Serve as a mentor and coach to team members delivering provider education and real-time documentation support. - Analyze provider performance measures in collaboration with CDI leadership to identify provider-specific education and documentation improvement opportunities. - Participate in quality improvement initiatives and internal/external audits related to clinical documentation integrity, coding accuracy, and regulatory compliance. - Assist audit teams by providing documentation support, responding to findings, and implementing corrective actions as needed. - Develop, coordinate, and complete internal auditing activities to ensure compliance with clinical documentation and coding standards. - Stay current on CDI industry standards, coding and documentation updates, regulatory changes, and clinical literature, and disseminate relevant information to staff and providers. - Participate in the interview and candidate evaluation process to support CDI leadership in identifying and selecting qualified team members. - Other duties as assigned. - Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. - Understand and comply with Information Security and HIPAA policies and procedures at all times. - Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties. Qualifications - BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required. - Minimum of 3 years of experience in clinical documentation improvement role required. - Minimum of 5 years nursing experience in adult acute care in med/surg, critical care, emergency, or PACU required. - Active RN, MD, DO, NP, or PA license required. - Certification minimum CCDS and/or CDIP required. - CCS required. - Experience with 3M and/or Epic is highly preferred. - In-depth knowledge of coding guidelines, ICD-10-CM/PCS, MS and APR DRG’s. - Strong understanding of clinical documentation improvement principles and practices. - Proficiency in Microsoft Office Suite. - Strong interpersonal skills, ability to communicate well at all levels of the organization. - Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses. - High level of integrity and dependability with a strong sense of urgency and results oriented. - Excellent written and verbal communication skills required. Working Conditions - Ability to work outside of normal business hours as needed. - Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes. Physical Demands - While performing the duties of this job, the employee is occasionally required to move around the work area; sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals, and telephones; extend arms; kneel; talk and hear. Mental Demands - The employee must be able to follow directions, collaborate with others, and handle stress. Work Environment - The noise level in the work environment is usually minimal.

Role Description The Manager, Clinical Documentation Improvement (CDI) is responsible for providing operational oversight and leadership for Accuity's Clinical Documentation Improvement programs, including day-to-day CDI operations and retrospective query writing services for client organizations. This role supports CDI leadership through staff management, auditing, reporting, education, mentoring, and client relationship management. The Manager collaborates with internal and client stakeholders to improve the accuracy, completeness, and integrity of clinical documentation, ensuring that the patient's true clinical picture is appropriately reflected while supporting compliant coding, reimbursement, and quality outcomes. Responsibilities - Clinical Documentation Improvement Operations: - Provide oversight of daily CDI operations and retrospective query writing activities. - Assist with chart and query review, approval, and auditing activities as necessary. - Ensure adherence to CDI best practices, organizational standards, client requirements, and regulatory guidelines. - Maintain the integrity of CDI processes by ensuring client-specific instructions, workflows, and query guidance remain current and accurate. - Review CDI dashboard to monitor KPI reports and operational metrics to evaluate program effectiveness and identify opportunities for improvement. - Prepare and monitor CDI Scorecards for POD and Clients. - Quality Assurance and Performance Management: - Conduct audits of clinical reviews and retrospective queries and maintain quarterly audit records for assigned staff. - Monitor query writer productivity and quality in accordance with departmental standards and policies. - Utilize audit findings, CPU leadership feedback, coding guidance, and industry best practices to evaluate performance and provide coaching. - Identify opportunities for individual and team performance improvement and implement corrective actions as needed. - Reviews cases for CDI Peer-to-Peer/escalations and leads client-facing discussions as CDI Subject Matter Expert. - Prepares case presentations and leads client facing alignment discussion. - Participates in client on-sites to optimize pilot engagement and client relationships. - Promote consistency, compliance, and quality across all CDI activities. - Leadership and People Management: - Provide direct supervision, mentoring, coaching, and development for assigned CDI team members. - Support onboarding, training, and continuing education initiatives for new and existing staff. - Conduct annual performance evaluations and address interim performance concerns when necessary. - Review and approve employee timecards each pay period. - Manage staffing resources, including time-off requests, to ensure adequate operational coverage. - Assist team members with workload management and provide direct support during periods of increased volume. - Client and Stakeholder Collaboration: - Develop and maintain productive relationships with client stakeholders and internal business partners. - Collaborate with CDI leadership, Medical Directors, Coding, DRG Validation, Client Managers, Revenue Cycle Analysts, Query Processors, and client healthcare teams to improve documentation outcomes. - Engage with client concurrent CDI teams to facilitate collaboration and support timely physician query responses. - Contribute to strengthening client relationships through proactive communication and issue resolution. - Participate in client meetings and operational discussions as needed. - Identify operational, quality, staffing, and client risks and proactively escalate issues with recommended mitigation strategies. - Program Implementation and Continuous Improvement: - Participate in new client implementations and team activities. - Contribute to the development of CDI workflows and operational processes for new and existing clients. - Support pilot programs by assisting with issue triage, workflow optimization, and stakeholder communication. - Assist CDI leadership with special projects, departmental initiatives, and process improvement efforts. - Recommend operational enhancements that improve efficiency, quality, and client outcomes. - Utilize CDI performance dashboards and trend analysis to drive operational improvements and support leadership decision-making. - Other Duties as Assigned: - Support departmental and organizational initiatives that contribute to overall business objectives. Qualifications - CCDS (Certified Clinical Documentation Specialist) and/or CDIP (Certified Documentation Improvement Practitioner) certification required. - Bachelor of Science in Nursing (BSN) preferred. - Other healthcare-related degrees may be considered based on relevant experience and qualifications. - Minimum five (5) years of Clinical Documentation Improvement management experience. - Experience overseeing CDI operations, auditing, productivity management, and quality improvement initiatives. - Experience collaborating with physicians, coding professionals, healthcare leaders, and multidisciplinary teams. - Experience utilizing electronic medical records (EMRs), encoder systems, CDI technology platforms, and reporting tools. Core Competencies - Strong leadership, coaching, and employee development skills. - Excellent verbal, written, and interpersonal communication abilities. - Ability to effectively lead and engage remote teams. - Strong organizational skills with attention to detail and accuracy. - Ability to manage multiple priorities and deadlines in a fast-paced environment. - Critical thinking and problem-solving capabilities. - Ability to analyze data and utilize performance metrics to drive improvement. - Strong relationship-building and stakeholder management skills. - Commitment to quality, compliance, and continuous improvement. - High level of accountability, professionalism, and integrity. - Ability to work independently while fostering collaboration across teams. - Proficiency with Microsoft Office applications including Word, Excel, Outlook, PowerPoint, and Teams. - Ability to learn and navigate multiple EMRs, encoder systems, and healthcare technology platforms. Additional Requirements - Physical Requirements: - The requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodations. - Unless otherwise indicated, Accuity positions require interaction with people and technology while either sitting or standing. - Employees must be able to communicate via phone, email, etc. and sit for extended periods of time, with or without reasonable accommodations. - Physical effort and exposure to physical risk are limited to that of an office role/environment. - Position and Employment Statement: - While this job description is intended to be an accurate reflection of the job requirements, management reserves the right to modify, add or remove duties from a job and to assign other duties as necessary and at any time. - All positions at Accuity Delivery Systems, LLC, are at-will employment, and a position description is not a guarantee of a job or of job responsibilities.

Role Description Baptist Health is looking to add a Clinical Document Integrity Specialist in our CDI Department at Baptist Metro Square. This is a Full Time remote opportunity. As a Clinical Document Integrity Specialist, you will be responsible for: - Facilitating the improvement in the overall quality, completeness and compliance of the clinical documentation through extensive interaction with physicians, nursing, other patient care givers and coding staff to ensure that documentation supports the DRG assigned to each case to the extent that the physician concurs. - Ensuring that the documentation used in measuring patient outcomes is accurate and complete by conducting initial and concurrent reviews on admissions. - Monitoring assignment of patient status; utilizing designated and approved tools to track progress; serving as a resource to physicians and coding regarding issues related to the appropriateness for inpatient DRG assignment. Qualifications - Associate of Science in Nursing Required - Doctor of Medicine Preferred - Bachelor of Science in Nursing Preferred - Certified Documentation Improvement Professional (CDIP) Preferred - Certified Clinical Documentation Specialist (CCDS) Preferred - Licensed Advanced Registered Nurse Practitioner Required - Licensed Registered Nurse Required - Licensed Physician Assistant Required - Licensed Nurse Practitioner Required Requirements - 3-5 Years Coding Experience - 3-5 Years Utilization Review Experience Preferred - 3-5 Years Knowledge of Coding Clinic Guidelines Preferred - 3-5 Years Experience working in an Acute Care setting Required Company Description Baptist Health is recognized as a top place to work in health care, caring for more patients in Northeast Florida than any other provider, ranking as “most preferred” for more than 30 years. We’re Jacksonville's only locally governed, faith-based, not-for-profit health system and provide a full spectrum of preventive and specialty care through 200+ locations and six hospitals. Our centers of excellence include: - Baptist MD Anderson Cancer Center - Baptist Heart Hospital - Baptist Neurological Institute - Wolfson Children's Hospital