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Clinical Document Improvement Specialist Supervisor - San Bernardino and Glendale, CA

UnitedHealth Group

San Bernardino, CA
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Job Details

743353 Clinical Document Improvement Specialist Supervisor San Bernardino and Glendale CA

Clinical Document Improvement Specialist Supervisor - San Bernardino and Glendale, CA (743353)

Position Description

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)


$5,000 Sign on Bonus for all External Candidates!

The Clinical Document Improvement Specialist Supervisor -  is responsible for providing CDI program oversight and 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 LCDS oversight and practice is to support the CDI manager function by providing staff oversite, serve as an additional resource as well as perform CDI role function.  The Supervisor will   assure via assessment, and teaching staff and providers the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.  
This position collaborates with CDI manager, providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient.  The CDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals and core values of Optum 360.  This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care. 
*** Travel is required between facilities and may be required to meetings at other facilities. Locations are St. Bernardine Medical Center in San Bernardino, CA AND Glendale Memorial Hospital in Glendale, CA***
Primary Responsibilities: 
  • Assists CDI Manager with chart audits, quality audit and KPI audits
  • Assists CDI Manager with running reports, attends on site meetings as directed
  • Assists with CDI staff training and orientation
  • Oversees and leads workflow for CDI staff
  • Develops physician teaching and on site presentations
  • Assist CDI manager with projects or tasks as needed
  • Time card approval
  • Coaching
  • Evaluations
  • Other duties as assigned 
  • Communicates performance expectation of leadership to staff level CDI staff.
  • Oversees that CDI staff are providing expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided
  • Ensures and oversees 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 level review and assessment, and effectively articulating recommendations for improvement, and the rational 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
  • Performs regular rounding with unit-based physicians
  • Provides face-to-face educational opportunities with physicians.
  • Provides complete follow through on all requests for clarification or recommendations for improvement
  • Leads the development and execution of physician education strategies resulting in improved clinical documentation
  • Ensures  timely feedback to providers regarding clinical documentation opportunities for improvement and successes
  • Ensures effective utilization of the CAC / Midas Clinical Documentation Improvement Focus Study, ensuring documentation of  all verbal, written, electronic clarification activity
  • Utilizes only the Optum360 approved forms, whether paper or electronic
  • Proactively develops a reciprocal relationship with the HIM Coding Professionals
  • Coordinate and conducts regular meeting with HIM Coding Professionals to monitor retrospective query rate and address issues
  • Engages and consults with Physician Advisor when needed, per the escalation process, to resolve provider 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
  • Sets team direction, resolves problems and provides guidance to members of own team.
  • Adapts departmental plans and priorities to address business and operational challenges.
  • Influences or provides input to forecasting and planning activities.
Required Qualifications:
  • 5+ years acute care hospital clinical RN experience OR Foreign Medical Graduate with CDI experience
  • 3+ years of experience in Clinical Documentation Improvement
  • Must have proficiency using a PC in a Windows environment, including Microsoft Word,  Excel, Power Point, Electronic Medical Records (Cerner is preferred) and CAC technologies
  • Experience communicating & working closely with Physicians
Preferred Qualifications:
  • Previous experience in case management and / or critical care
  • CCDS, CCDP or CCS certification
  • BSN degree or equivalent preferred
  • Experience leading projects with complex responsibilities and timelines
  • Leadership experience
  • Excellent verbal and written skills including strong organizational skills
  • Ability to multi-task
  • Ability to lead teams
  • Ability to present, speak in public

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world?s large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.



Job Keywords: RN, Registered Nurse, CCDS, Certified Clinical Documentation Specialist, Case Management, CDIP, Clinical Documentation Improvement Professional, CCS, Certified Coding Specialist, CDI, Dignity Health, St. Bernardine Medical Center in San Bernardino, CA

Job Details

  • Contest Number743353
  • Job TitleClinical Document Improvement Specialist Supervisor - San Bernardino and Glendale, CA
  • Job FamilyMedical and Clinical Operations
  • Business SegmentOptumInsight

Job Location Information

  • San Bernardino, CA
    United States
    North America
  • Other LocationsGlendale, CA

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelManager
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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