OPT Clinical Documentation Improvement Jobs
Clinical Documentation Improvement jobs are a strong fit for F-1 OPT students with health information management, nursing, or coding backgrounds. Most roles qualify as STEM OPT extensions under CIP codes tied to health informatics. Employers in hospital systems and revenue cycle management firms regularly sponsor H-1B visas for CDI specialists.
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Get Access To All JobsINTRODUCTION
Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.
ROLE AND RESPONSIBILITIES
The Clinical Document Improvement Specialist - (CDS) 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 CDS oversight and practice is to assess 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 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.
In this position the CDS will utilizing the Optum™ CDI 3D technology that is assisting hospitals to improve data quality to accurately reflect the quality of care provided and ensure revenue integrity.
Our three-dimensional approach to CDI technology, paired with best-practice adoption methodology and change management support, is helping hospitals make a real impact on CDI efficiency and effectiveness.
- Increase in identification of cases with CDI opportunities, with automated review of 100% of records
- Improved tracking, transparency and reporting related to CDI impact, revenue capture, trending, and compliance
- Easing the transition to ICD-10 by improving the specificity and completeness of clinical documentation, resulting in more accurate coding
This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.
Work Location: onsite at client hospital
Primary Responsibilities:
- Provides 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 condition and acuity of care provided
- Conducts 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
- Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
- Provides face-to-face educational opportunities with physicians on a regular basis
- 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
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
- Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activities
- Utilizes only the Optum360 approved clarification forms
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Coordinates and conducts regular meetings with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
- Engages and consultations with Physician Advisor / VPMA 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
BASIC QUALIFICATIONS
- 3+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
- Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and electronic medical records
- Experience communicating & working closely with physicians
- Ability to work onsite
PREFERRED QUALIFICATIONS
- BSN degree if a RN
- CCDS, CDIP or CCS certification
- Experience in clinical documentation improvement
- CAC experience (Computer Assistant Coding)
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone - of every race, gender, sexuality, age, location and income - deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
INTRODUCTION
Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.
ROLE AND RESPONSIBILITIES
The Clinical Document Improvement Specialist - (CDS) 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 CDS oversight and practice is to assess 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 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.
In this position the CDS will utilizing the Optum™ CDI 3D technology that is assisting hospitals to improve data quality to accurately reflect the quality of care provided and ensure revenue integrity.
Our three-dimensional approach to CDI technology, paired with best-practice adoption methodology and change management support, is helping hospitals make a real impact on CDI efficiency and effectiveness.
- Increase in identification of cases with CDI opportunities, with automated review of 100% of records
- Improved tracking, transparency and reporting related to CDI impact, revenue capture, trending, and compliance
- Easing the transition to ICD-10 by improving the specificity and completeness of clinical documentation, resulting in more accurate coding
This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.
Work Location: onsite at client hospital
Primary Responsibilities:
- Provides 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 condition and acuity of care provided
- Conducts 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
- Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
- Provides face-to-face educational opportunities with physicians on a regular basis
- 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
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
- Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activities
- Utilizes only the Optum360 approved clarification forms
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Coordinates and conducts regular meetings with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
- Engages and consultations with Physician Advisor / VPMA 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
BASIC QUALIFICATIONS
- 3+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
- Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and electronic medical records
- Experience communicating & working closely with physicians
- Ability to work onsite
PREFERRED QUALIFICATIONS
- BSN degree if a RN
- CCDS, CDIP or CCS certification
- Experience in clinical documentation improvement
- CAC experience (Computer Assistant Coding)
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone - of every race, gender, sexuality, age, location and income - deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
See all OPT Clinical Documentation Improvement Jobs
Sign up for free to unlock all listings, filter by visa type, and get alerts for new OPT Clinical Documentation Improvement Jobs.
Get Access To All JobsTips for Finding OPT Sponsorship in Clinical Documentation Improvement
Target hospital systems and large health networks
Large academic medical centers and integrated health systems like Kaiser Permanente and HCA Healthcare have established immigration programs. They hire CDI specialists regularly and are far more likely to have the HR infrastructure to sponsor work visas than smaller clinics.
Confirm your degree qualifies for STEM OPT extension
Health informatics, health information management, and clinical informatics degrees typically qualify for a 24-month STEM OPT extension. Verify your CIP code with your DSO before applying, since this extension nearly triples your authorized work period.
Highlight clinical coding credentials in your application
AHIMA credentials like RHIA, RHIT, or CCS signal specialized competency to employers. CDI-specific certifications from ACDIS also strengthen your profile. Credentialed candidates face less employer hesitation around sponsorship because the specialized skill set justifies the investment.
Apply before your OPT start date, not after
Many CDI roles require onboarding compliance checks and credentialing that take weeks. Starting your search three to four months before OPT authorization begins gives employers enough runway to process paperwork without feeling pressured by your timeline.
Focus your search on revenue cycle and health IT firms
Companies like Ciox Health, Optum, and Nuance Communications hire CDI specialists at scale and have consistent H-1B sponsorship histories. Revenue cycle outsourcing firms often sponsor because qualified CDI candidates with clinical backgrounds are genuinely hard to find.
Be direct about your OPT status and remaining authorized period
CDI hiring managers often lack immigration experience. Briefly explaining that OPT provides immediate work authorization, and that a STEM extension may apply, removes ambiguity early. Employers who understand the timeline are significantly more likely to move forward.
Clinical Documentation Improvement OPT: Frequently Asked Questions
Do Clinical Documentation Improvement jobs qualify for the STEM OPT extension?
They can, depending on your degree. CDI roles are not inherently STEM-designated, but if your degree is in health informatics, health information management, or clinical informatics, your CIP code may qualify for the 24-month STEM extension. Confirm with your DSO before applying, since this varies by program and institution.
Can I work as a CDI specialist on OPT without prior clinical experience?
Some employers accept candidates with strong health information management or coding coursework, but most CDI roles expect at least a foundational understanding of ICD-10-CM/PCS coding and clinical documentation standards. Entry-level CDI positions at larger health systems are more structured for new graduates than roles at smaller facilities, which typically expect hands-on experience.
How do I find CDI employers who are open to OPT sponsorship?
Browse CDI roles on Migrate Mate, which filters for employers actively open to sponsoring F-1 OPT students. Large hospital systems, revenue cycle management firms, and health IT companies are the most consistent sponsors. Searching by employer type rather than job title alone helps you avoid wasting time on roles where sponsorship is not realistic.
What work authorization documents do I need to start a CDI job on OPT?
You need your EAD card showing valid work authorization dates, your valid F-1 visa, your I-20 with your DSO's OPT authorization signature, and your passport. Some hospital employers also require I-9 completion before your first day, so have all documents ready before your start date. Do not begin work before your EAD start date.
Is Clinical Documentation Improvement a realistic path to H-1B sponsorship?
Yes, for candidates with the right credentials. CDI specialists with RHIA, RHIT, or CDIP certifications are in genuine demand, and large health systems have dedicated immigration counsel. The specialty occupation argument for CDI typically rests on the requirement for a degree in health information management or a directly related clinical field, which makes H-1B petitions defensible.