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Clinical Documentation Integrity Specialist – Hybrid Greenbrae Ca

5+ years
$71,600 to $140,600
10 April 8, 2025
Job Description
Job Type: Hybrid Remote Education: B.Sc./M.Sc/B.Pharm/M.Pharm/Life Science Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

 

Job Title: Clinical Document Improvement Specialist (CDS)

Company: Optum (a UnitedHealth Group company)
Location: Greenbrae, California, USA (Hybrid – 25% onsite)


Company Overview:

  • Parent Organization: UnitedHealth Group

  • Mission: To help people live healthier lives and make the health system work better for everyone

  • Focus Areas: Care delivery, pharmacy benefits, data integration, health equity

  • Work Culture: Guided by diversity, inclusion, career development, and innovation


Position Summary:

The Clinical Document Improvement Specialist (CDS) provides expert-level review of inpatient medical records to ensure accuracy, completeness, and specificity in documentation. This role supports accurate coding, revenue integrity, and quality reporting. The CDS will collaborate with physicians and healthcare teams to improve documentation practices using the Optum® CDI 3D technology.


Work Environment:

  • Setting: Inpatient hospital setting

  • Remote Work: Hybrid – 25% onsite required

  • Location: Must reside within a commutable distance to Greenbrae, CA

  • Patient Interaction: No direct patient care responsibilities


Primary Responsibilities:

  • Review inpatient records within 24–48 hours of admission

  • Identify documentation gaps and provide clarifications to providers

  • Communicate with providers to improve specificity and completeness

  • Conduct rounding with physicians and provide documentation support

  • Lead physician education on documentation best practices

  • Utilize Optum CDI 3D technology for documentation and query tracking

  • Collaborate with HIM Coders, Care Coordination, and Quality teams

  • Engage Physician Advisors or VPMA for escalation, if needed

  • Maintain compliance with all CDI and documentation guidelines


Required Qualifications:

  • 5+ years of acute care hospital RN experience OR Medical graduate with 1+ year CDI experience

  • 1+ year of clinical documentation improvement experience in an inpatient setting

  • Proficiency in Microsoft Office and Electronic Medical Records (EMR)

  • Experience collaborating with physicians

  • Must live within commuting distance to Greenbrae, CA


Preferred Qualifications:

  • Education: BSN (if RN)

  • Certifications: CCDS, CDIP, or CCS

  • Technology: Experience with Computer-Assisted Coding (CAC)


Technology Used:

  • Optum® CDI 3D

  • Microsoft Office Suite

  • Electronic Medical Records (EMR)


Compensation & Benefits:

  • Salary Range: $71,600 – $140,600 annually (based on experience, location, etc.)

  • Benefits:

    • Comprehensive health insurance

    • 401(k) with company contribution

    • Equity stock purchase plan

    • Incentive and recognition programs

    • Paid time off and more

  • Compliance: Must pass a drug test prior to employment


Workplace Values & Commitments:

  • Focus on health equity and environmental impact

  • Commitment to diversity, equity, and inclusion (DEI)

  • EEO employer — welcomes applicants regardless of race, gender, identity, age, disability, or veteran status

  • Drug-free workplace


Application Links: