Join Optum, a global leader in healthcare technology, dedicated to improving lives by connecting people with essential care, pharmacy benefits, and resources. Our inclusive culture fosters collaboration and growth, offering comprehensive benefits and career development. As a Clinical Documentation Integrity Specialist, you will play a crucial role in optimizing healthcare outcomes by ensuring the accuracy and completeness of medical records.

This position focuses on reviewing inpatient medical records to guarantee that all clinical findings and conditions are precisely documented. The goal is to accurately reflect patient severity and the acuity of care provided. Importantly, this role does not involve direct patient care duties or interactions.

Conduct expert-level concurrent reviews of inpatient medical records within 24-48 hours of admission.

Identify and address documentation gaps, inconsistencies, or lack of specificity that could impact diagnosis capture, principal diagnosis, SOI/ROM, DRG assignment, and quality metrics.

Initiate and manage compliant electronic queries to obtain necessary clinical clarifications, ensuring they are non-leading and adhere to AHIMA and organizational standards.

Perform daily follow-up on outstanding queries to facilitate timely documentation resolution.

Accurately document all review findings, monitor, and resolve queries using approved CDI tools and platforms like Midas Clinical Documentation Improvement Focus Study.

Maintain clear audit trail notes for internal and external reviews.

Participate in physician education initiatives to promote best practices in documentation.

Stay updated on evolving documentation, coding, and regulatory guidelines impacting reimbursement and quality outcomes.

Collaborate with Medical Coding Professionals to reconcile documentation and final DRG assignments.

Partner with the Onshore Team, engaging with Physician Advisors, Care Coordination, and Quality Management to identify systemic documentation improvement opportunities.

A valid MBBS degree (Indian/FMG credentials) is required.

While not mandatory, experience in patient handling, critical care, or case management is advantageous, providing a strong understanding of complex patient needs and interdisciplinary coordination.

Proficiency in basic Microsoft Word and Excel, along with a foundational understanding of EMR/EHR systems, is necessary.

Familiarity with healthcare compliance, clinical documentation, medical terms, HIPAA, and the general principles of medical coding (ICD-10) is essential. Enhanced knowledge of ICD-10 is a plus.

Proven excellent verbal and written communication skills are vital for articulating documentation gaps and explaining the rationale for clinical queries.

Certification such as the Certified Clinical Documentation Specialist (CCDS) is preferred.

Kindly note that this role involves no face-to-face interaction with physicians due to its offshore nature.