Clinical Documentation Specialist Job at Optum for MBBS Doctors
If you are looking for a rewarding clinical documentation specialist job, this opportunity at Optum India offers a dynamic platform for MBBS professionals to grow in the healthcare domain. This role blends clinical expertise with documentation accuracy, making it ideal for candidates exploring MBBS jobs, Optum careers, and long-term growth in healthcare operations.
Job Details:
- Job Title: Clinical Documentation Integrity Specialist
- Employment Type: Full-time
- Industry: Medical and Diagnostic Laboratories
- Job Function: Health Care Provider
About the Company
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. As part of UnitedHealth Group, the company focuses on improving health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. . Professionals exploring Optum careers and Optum jobs will find opportunities to make a meaningful impact on communities while advancing health optimization on a global scale.
Job Description
This clinical documentation specialist job involves performing expert-level concurrent reviews of inpatient medical records within 24–48 hours of admission. The role focuses on identifying documentation gaps, inconsistencies, or insufficient specificity impacting diagnosis capture, Principal diagnosis, SOI/ROM, DRG assignment, and quality metrics.
This position is well-suited for candidates seeking MBBS jobs that leverage clinical knowledge in a non-clinical environment. There is no face-to-face interaction with physicians due to the offshore nature of the role.
Qualifications
Required Qualifications
- Education: Must possess a valid MBBS degree (Indian/FMG credentials).
- Experience: Experience in patient handling and care, critical care or case management is preferred as it provides a foundational understanding of complex patient needs, resource allocation, and interdisciplinary coordination required in high-acuity healthcare settings.
Technical Skills:
- Basic understanding of Microsoft Word and Excel.
- Basic understanding of EMR/EHR systems.
Standards Knowledge:
- Basic familiarity with healthcare compliance, clinical documentation, medical terms and concepts, HIPAA, and general idea of medical coding (ICD-10).
- Enhanced knowledge of ICD-10 will be preferential.
Key Responsibilities
Clinical Documentation Review
- Perform expert-level concurrent reviews of inpatient medical records within 24–48 hours of admission.
- Identify documentation gaps, inconsistencies, or insufficient specificity impacting diagnosis capture, Principal diagnosis, SOI/ROM, DRG assignment, and quality metrics.
Clinical Clarification & Query Management
- Initiate and manage compliant queries exclusively through electronic means to obtain necessary clinical clarification.
- Ensure queries are clinically supported, non-leading, and aligned with AHIMA and organizational query standards.
- Conduct daily follow-up on outstanding queries to support timely documentation resolution.
Documentation & System Utilization
- Accurately document all review findings, monitor and resolve queries, responses, and outcomes using approved CDI tools and platforms (e.g., Midas Clinical Documentation Improvement Focus Study or equivalent systems).
- Maintain clear notes for audit trails to support internal review and external audits.
Education & Continuous Improvement
- Participate in structured physician education initiatives to enhance awareness of documentation requirements and best practices.
- Stay current with evolving documentation, coding, and regulatory guidelines affecting inpatient reimbursement and quality outcomes.
Collaboration & Interdisciplinary Engagement
- Work collaboratively with Medical Coding Professionals to reconcile documentation and final DRG assignment.
- Partner with the Onshore Team who interacts with Physician Advisors, Care coordination and Quality Management teams to identify systemic documentation improvement opportunities.
- Support organizational initiatives related to documentation accuracy, compliance, and performance improvement.
Compliance
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Comply with the terms and conditions of the employment contract, company policies and procedures, and any directives including transfer, re-assignment, shift changes, flexibility of work benefits, alternative work arrangements, and business environment decisions.
