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RN Clinical Documentation Improvement Specialist - Long Island, NY - $5K Sign on Bonus for External Candidates

UnitedHealth Group

Long Island, NY
Job Code:
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Job Details

751467 RN Clinical Documentation Improvement Specialist Long Island NY 5K Sign on Bonus for External Candidates

RN Clinical Documentation Improvement Specialist - Long Island, NY - $5K Sign on Bonus for External Candidates (751467)

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)
The Clinical Document Improvement Specialist - (CDS) 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 CDS oversight and practice is to assess 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 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.  Utilizing clinical expertise and clinical documentation improvement practices and 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.
**This is a full time onsite position, Monday-Friday, day hours
This position could be located at one of the following locations and/or float to various locations:
Bayshore, Staten Island, Manhasset, New Hyde Park, Valley Stream, Plainview, Syosset, Huntington, Forest Hills and  Manhattan**
Primary Responsibilities:
  • Provides expert level review of inpatient clinical records within 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
  • 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 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
  • 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
  • Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
  • Ensures effective utilization of the Optum360 CAC software
  • Utilizes only the facility/Optum 360 approved forms, whether paper or electronic
  • Steers the development and implementation of education plans for the interdisciplinary care team to promote accurate and complete documentation in the medical  record
  • 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 to resolve provider issues regarding  answering clarifications and participation in the clinical documentation improvement process
  • Actively engages with healthcare team on the assigned patient unit to continually evaluate and spearhead clinical documentation improvement opportunities
Required Qualifications:
  • Active, unrestricted RN license
  • 5 + years of clinical experience working in an inpatient hospital, acute care setting – ICU, Critical Care, Med/Surg, ED and/or  Home Care experience
  • Computer proficiency: recent working experience with Microsoft Outlook, Word, Excel and ability to navigate in a Windows based environment
Preferred Qualifications:
  • Previous CDI experience -  conducting efficient and regular documentation reviews and evaluating the quality and efficiency of documentation practice
  • Coding experience with ICD-10 CM and PCS
  • BSN/MSN degree
  • Chart review experience
  • CDI Specialist Certification through AHIMA or ACDIS 
  • CCS  (Certified Coding Specialist)
  • Ability to interact with physicians and adapt communication style
  • Strong organizational skills
  • Effective verbal and written communication skills; ability to give presentations  
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)
**PLEASE NOTE** The sign on bonus is only available to external candidates. Candidates who are currently working for a UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time, or per diem basis (“Internal Candidates”) are not eligible to receive a sign on bonus.
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: , ICD 10, CCS, coding, RN, Registered Nurse, Nurse, critical care, BSN, clinical documentation improvement, CDIS, CCDS, CDI, DRG, CDIP, chart review, Staten Island University Hospital, Staten Island, NY, New York, Northwell, Bayshore, Staten Island, Manhasset, New Hyde Park, Valley Stream, Plainview, Syosset, Huntington, Forest Hills and  Manhattan

Job Details

  • Contest Number751467
  • Job TitleRN Clinical Documentation Improvement Specialist - Long Island, NY - $5K Sign on Bonus for External Candidates
  • Job FamilyNursing
  • Business SegmentOptumInsight

Job Location Information

  • Long Island, NY
    United States
    North America
  • Other LocationsNEW HYDE PARK, NY
    Staten Island, NY
    Manhattan, NY

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • 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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