Clinical Document Improvement Specialist (CDI) Manager – North State Market - Multiple Locations

    • Redding, CA

Position Description

Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

The Clinical Document Improvement Specialist Manager 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 Manager oversight and practice is to support the CDI Director function by providing staff oversite, assisting with monthly reporting and auditing, as well as, mentoring and orientation of new staff and attending client meetings. The Manager 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: the CDI Director, 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.

This position requires local travel within the North State Market consisting of 3 hospitals including 1 in Redding, 1 in Red Bluff and 1 in Mount Shasta

Primary Responsibilities:

  • Assists CDI Director with chart audits, quality audit and KPI audits
  • Assists CDI Director with running reports, attends on site meetings as directed
  • Oversees CDI staff training and orientation
  • Oversees and leads workflow for CDI staff
  • Ensures adequate staffing for the workload, and steps in to assist teams when workload is in excess of what the team can complete
  • Develops physician teaching and on site presentations
  • Assist CDI Director with projects or tasks as needed
  • Time card approval
  • Coaching
  • Evaluations
  • 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
  • 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 / Cerner EMR (electronic medical record) 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


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:
  • RN or Foreign Medical Graduate with 3+ years of CDI experience
  • 1+ years of CDI supervisory/management experience
  • CCDS, CDIP or CCS certification
  • Comfortable communicating & working closely with Physicians
  • Willingness to work out of Mercy Medical Center Redding and visit Mercy Medical Center Mount Shasta and St. Elizabeth Community Hospital in Red Bluff requiring in the range of 25% car travel
  • Excellent verbal and written skills including strong organizational skills
  • Strong understanding of Microsoft, Word, Excel, and work related software


Preferred Qualifications:
  • Previous experience in case management and / or critical care
  • BSN degree


Soft Skills:
  • Ability to multi-task
  • Ability to lead teams
  • Ability to present, speak in public
  • Ability to lead projects with complex responsibilities and timelines


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)

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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.

Keywords: CDI, Manager, CDI Manager, North State , Redding, reporting, chart audits, CCDS, CDIP, CCS, CA, California

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