Remote RN Clinical Documentation Improvement Specialist


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Requisition Number: 2205975
Job Category: Medical & Clinical Operations
Primary Location: Richardson, TX
(Remote considered)

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.


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: 

  • Active, unrestricted Registered Nurse license or non-licensed medical school graduate
    • RN: 3+ years CDI experience
    • Medical School Graduate: 2+ years of CDI experience
  • Experience communicating & working closely with Physicians
  • Familiar with medical review documentation process
  • Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and Electronic Medical Records
  • Proven solid attention to detail and excellent organizational skills
  • Proven ability to multi-task in a fast paced and deadline driven environment

Preferred Qualifications:  

  • BSN degree
  • Registered Nurse
  • Current certification as a CCDS, CDIP or CCS
  • 2+ years CDI experience
  • Excellent verbal and written skills including solid organizational skills

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

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New Jersey, New York, Rhode Island or Washington residents is $70,200 to $137,800 annually. 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.