Clinical Documentation Integrity Specialist
Company: Optum (UnitedHealth Group)
Location: Noida, Uttar Pradesh, India
Job Category: Medical & Clinical Operations
Job Type: Full-Time
Employment Type: Regular
Requisition Number: 2345942
Experience Required: Experience in patient care, clinical practice, critical care, or case management preferred
Education: MBBS (Indian or Foreign Medical Graduate)
About Optum
Optum, a part of UnitedHealth Group, is a global healthcare organization dedicated to improving health outcomes through advanced technology, data-driven insights, and integrated healthcare services. The company connects individuals with healthcare providers, pharmacy benefits, and essential resources to support healthier lives.
Optum fosters an inclusive and collaborative workplace where professionals contribute to improving global healthcare systems while advancing their careers.
Job Overview
Optum is seeking a Clinical Documentation Integrity Specialist to support accurate and comprehensive clinical documentation in inpatient medical records. This role focuses on reviewing medical records, identifying documentation gaps, initiating compliant clinical queries, and collaborating with coding teams to ensure accurate diagnosis capture, appropriate DRG assignment, and improved clinical documentation quality.
The specialist plays a key role in enhancing documentation accuracy, supporting regulatory compliance, and improving healthcare data quality that directly impacts reimbursement, patient care reporting, and quality metrics.
Key Responsibilities
Clinical Documentation Review
Conduct concurrent expert-level reviews of inpatient medical records within 24–48 hours of patient admission.
Identify documentation gaps, inconsistencies, or lack of specificity that may affect diagnosis capture, principal diagnosis identification, severity of illness (SOI), risk of mortality (ROM), and DRG assignment.
Ensure clinical documentation accurately reflects patient conditions, treatments, and outcomes.
Clinical Query Management
Initiate and manage compliant clinical queries through electronic documentation systems to obtain necessary clinical clarification.
Ensure queries follow industry standards and remain clinically supported, objective, and non-leading in accordance with AHIMA guidelines.
Monitor and follow up on outstanding queries to ensure timely documentation clarification and resolution.
Documentation and System Management
Accurately record review findings, queries, responses, and outcomes within approved CDI platforms and documentation tools.
Maintain clear documentation notes and audit trails to support internal quality checks and external audits.
Utilize clinical documentation improvement systems such as Midas Clinical Documentation Improvement Focus Study or similar platforms.
Education and Documentation Improvement
Participate in physician documentation education initiatives aimed at improving clinical documentation quality and compliance.
Stay updated with evolving healthcare documentation standards, regulatory requirements, and coding guidelines affecting reimbursement and quality outcomes.
Cross-Functional Collaboration
Work closely with medical coding professionals to reconcile documentation details and ensure accurate DRG assignment.
Collaborate with onshore teams including physician advisors, care coordination teams, and quality management professionals.
Support organizational initiatives aimed at improving documentation accuracy, compliance, and operational efficiency.
Compliance and Governance
Adhere to internal company policies, healthcare compliance requirements, and regulatory documentation standards.
Ensure all clinical documentation processes align with coding regulations, healthcare quality measures, and audit requirements.
Required Qualifications
Educational Qualification
MBBS degree (Indian Graduate or Foreign Medical Graduate).
Professional Experience
Experience in patient care, clinical practice, critical care, or case management is preferred.
Understanding of complex patient management and interdisciplinary care coordination is advantageous.
Technical Skills
Basic proficiency in Microsoft Word and Microsoft Excel.
Familiarity with Electronic Medical Records (EMR) or Electronic Health Records (EHR) systems.
Clinical and Compliance Knowledge
Basic understanding of clinical documentation practices, medical terminology, and healthcare compliance.
Familiarity with HIPAA regulations and healthcare privacy standards.
Working knowledge of ICD-10 coding concepts is preferred.
Communication Skills
Excellent verbal and written communication skills to clearly explain documentation gaps and clinical rationale in queries.
Work Environment Note
This role is based in an offshore operational environment, and therefore there is no direct face-to-face interaction with physicians.
Preferred Qualifications
Certification such as Certified Clinical Documentation Specialist (CCDS) or equivalent professional credential.
Why Join Optum
Optum provides healthcare professionals with opportunities to work on large-scale healthcare transformation initiatives while leveraging advanced technologies and global collaboration. Employees benefit from career development programs, inclusive workplace culture, and opportunities to contribute to improving healthcare delivery worldwide.
Job Details
Business Segment: Optum
Schedule: Full-Time
Shift: Day Shift
Travel Requirement: No Travel Required
Telecommuter Position: No
Country: India
Uttar Pradesh :
Agra | Gajraula | Gautam buddha Nagar | Ghaziabad | Gorakhpur | Greater Noida | Jhansi | kanpur | Lucknow | Mathura | Noida | Park City | Prayagraj | Satyamev | Varanasi |Gujarat :
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amritsar | Bathinda | Bela | Chandigarh | ludhiana | Moga | Mohali | Patiala | Phagwara | Rajpura |Andra Pradesh :
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Banasthali | Bhiwadi | Jaipur | Pilani | Udaipur |Karnataka :
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Bhopal | Dewas | Gwalior | Indore | Khandwa | Khargone | Pithampur | Ujjain |Odisha :
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Bilaspur | Eot Municipality | Raipur |Uttarakhand :
Dehradun | Halifax | Nainital | Rishikesh | Roorkee |Delhi :
Delhi | India | New Delhi | PAN-India |Assam :
Dibrugarh | Diburghar | Guwahati |West Bengal :
Digha | Kolkata | Mukundapur |Goa :
Goa | Panaji | Verna |Bihar :
Hajipur | Patna |Kerala :
Kannur | Kochi | Malappuram | Thiruvananthapuram | Trivandrum |Pondicherry (Puducherry) :
Pondicherry (Puducherry) |Jharkhand :
Ranchi |Sikkim :
Rangpo |India :
Siliguri |Illinois :
Abbott Park | Bloomingdale | Champaign | Chicago | Deerfield | Glenview | Lake Forest | Lombard | Naperville | Norridge | Park RIdge | Round Lake |Maryland :
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Anchorage | Barrow | Bethel | Juneau | Sitka | Wrangell |Massachusetts :
Andover | Billerica | Boston | Cambridge | Devens | Lexington | Massachusetts | Medford and Somerville | Rockland |Wisconsin :
Appleton | Kenosha | Pleasant Prairie | Portage | Waukesha |United states :
Arizona | Buffalo Grove | Clayton | Downers Grove | fairmont | Georgia | Keene | Michigan | Mt. Pleasant | New Jersy | OH | Piedmont | Salisbury | United States | Whitesboro | Winston-Salem |Georgia :
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Bangor | Brewer |New Jersey :
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Batavia | Blue Ash | Cincinnati | Cleveland | Columbus, | Dayton | Erie | Evendale | Franklin | Hamilton | Huber Heights | Kings Mills | Macedonia | Mason | Milford | Montgomery | Norwood | Oregoina | oxford | Waynesville |LA :
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Chengdu | Garden city | Kansas City | Lawrence | McPherson |North Carolina :
Concord | Lumberton | North Carolina |Michigan :
Detroit | Houghton Lake | Macomb | Southfield |North Dakota :
Dickinson |Minnesota :
Duluth | Eden Prairie | Fridley | Hibbing | Maple Grove | Minneapolis and St. Paul, Minnesota. | Minnetonka | St.Paul |Kentucky :
Edgewood | Ft MItchell | Louisville | Shelbyville |Arkansas :
Fort Smith |Kington :
Frank Scottile Blvd |Missouri :
Fulton | Milan | St. Louis |United States :
Hawai | kentucky | Sylmar | Woonsocket |Nebraska :
Hebron | Nebraska City |Hawaii :
Hilo | Honolulu |Tennessee :
Knoxville | Memphis | Nashville |Louisiana :
Lake Charles | Shreveport |Nevada :
Las Vegas | Tonopah | Tonopsh | Virginia |New Hampshire :
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Lisbon | Oeiras | Portugal |WI :
Madison | Wausau |Republic of Mexico :
Mexico |northeastern :
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Oklahoma City |Puerto Rico :
San Juan |Albama :
Tuscaloosa |D.C :
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Wilmington |North Rhine Westphalia :
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Bavaria |Bavaria :
Bayreuth | Erlangen | Munich | Regensburg | Wurzburg |Brandenburg :
Berlin |Baden-Wurttemberg :
Biberach an der Riß | Freiburg | Grenzach | Heidelberg | Karlsruhe | Konstanz | Stuttgart | Tubingen | Ulm |Hesse :
Darmstadt | Marburg |Hessen :
Frankfurt | Harveysburg |Germany :
Germany | GErmany |Lower Saxony :
Gottingen | Hannover | Leipzig |Saxony Anhalt :
Halle |Rotherbaum :
Hamburg |Rhineland Palatinate :
Ingelheim am Rhein | Mainz |Schleswig Holstein :
Kiel |Berlin :
Mitte |Mecklenburg Vorpommern :
Rostock |Saarland :
Saarbrucken |Switzerland :
Basel | Zurich |Serbia :
Belgrade | Serbia |Hungary :
Budapest |BULGARIA :
Bulgaria | Vedant |Denmark :
Copenhagen | Denmark |Europe :
Europe | France | Latvia | Lendava | Leuven | Poland | Slovenia | Spain |Finland :
Finland |Istanbul :
Istanbul | Turkey |Norway :
Norway | NOrway |Romania :
Romania |Belgium :
Wavre |Tipperary :
Ballydine |Cork :
Brinny | Ringaskiddy |Carlow :
Carlow |Republic of Ireland :
Cork | Dublin | Limerick | Waterford |Ulster :
Donegal |Meath :
Dunboyne |Dún Laoghaire :
Dún Laoghaire |Galway :
Galway |County Dublin :
Swords |Republic of China :
Beijing |China :
China | Quarry Bay |Liaoning :
Dalian |Zhejiang :
Hangzhou |Tokiyo :
Osaka | Tokyo |Shanghai Sai :
Shanghai Shi |Hubei :
Wuhan |Capital of Netherland :
Amsterdam |North Brabant :
Breda |Noord Holland :
Haarlem |South Holland :
Leiden |Netherlands :
Netherlands |Remote Australia :
Arkansas | Remote Australia |New South Wales :
Ballina | Sydney |Republic of Western Australia :
Nedlands |Queensland :
Queensland |Melbourne :
South Yarra |United Kingdom :
England | Harlow | Leeds | London | Maidenhead | Salt Lake City | Stevenage | Stirling | United Kingdom |North Yorkshire :
Harrogate |South Yorkshire :
Sheffield |Oxfordshire :
Witney |Ontario :
Richmond Hill | Uxbridge | Renfrew | North York | Mississauga | Australia |Canada :
Canada |Quebec :
Montreal |Brussels :
Brussels |Antwerp :
Heist op den Berg |Flemish Brabant :
Zaventem |South America :
Argentina | Peru |Brazil :
Brazil | Sao paulo |Attica :
Koropi | Athens |Greece :
Greece |North Island :
Auckland |New Zealand :
New Zealand |Austria :
Austria |Vienna :
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Barcelona |Madrid :
Madrid |Cebu Province :
Cebu City |Philippines :
Manila |Croatia :
Croatia |Zagreb :
Zagreb |Estonia :
Estonia | Tartu |Harju County (Maakond) :
Tallinn |Hà Nội :
Hanoi | Hà Nội |Ho Chi Minh :
Ho Chi Minh City |Italy :
Italy |Lombardy :
Rho |Jakarta :
Jakarta |East Java :
Surabaya |Japan :
Japan | Saitama |Tokyo :
Otemachi |North Ostrobothnia :
Oulu |Southwest Finland (Varsinais-Suomi) :
Turku |Remote Korea :
Remote Korea |Republic of Korea :
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Brentwood |Bucharest :
Bucharest |Buenos Aires :
Buenos Aires |Republic of Egypt :
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Ciudad de México | New Mexico |Dubai :
Dubai |Makkah :
Rabigh | King Abdullah Economic City | Najran | Jeddah | Riyadh | Khulais |Kuala Lumpur :
Kuala Lumpur |Kyiv Oblast :
Kyiv |Lima Region :
Lima |France :
Lyon | Paris |South Africa :
Midrand | South Africa |Nišava District :
Niš |Bohemia :
Prague |Chile :
Santiago |Bosnia and Herzegovina :
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Singapore |Sofia City :
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