Clinical Documentation Specialist
Company: HCA Healthcare
Location: Fort Lauderdale
Posted on: January 23, 2023
Job Description:
Description Clinical Documentation Specialist
Full Time, Day Shift, 1.0 FTE
East Florida Support Services*This role will be onsite at HCA
Florida Westside Hospital in Plantation, FL*The Clinical
Documentation (CDI) Specialist interprets information within the
company's electronic health records to ensure complete and accurate
provider documentation. As appropriate, generates and issues
compliant queries to physicians for conflicting, imprecise,
incomplete, illegible, or inconsistent clinical documentation.
Initiates contact with physicians to obtain complete and timely
query responses.
- Performs high priority initial concurrent review and re-reviews
of clinically indicated conditions or procedures supported by the
appropriate assignment of severity of illness, expected risk of
mortality, intensity of service and resource consumption, which in
turn accurately portrays quality outcomes ratings, reduces
compliance risks, and captures appropriate reimbursement
- Analyzes documented and clinically supported conditions in
multiple electronic health record technologies to ensure complete
documentation that can be coded to the highest level of
specificity
- Demonstrates knowledge of Official Coding Guidelines and the
DRG Classification System to insure regulatory compliance related
to the CDI and coding functions
- As appropriate for DRG impact, assigns Working and Target DRG
if query response results in a primary diagnosis, procedure, and/or
cc or mcc that changes the DRG due to more accurate
documentation
- Thoroughly documents reviews, query follow up, and other
pertinent information in designated systems by established
deadlines * Achieves and maintains key operating metrics consistent
with CDI program requirements Physician Queries:
- Using critical thinking skills, independent discretion, and
clinical judgement, determines when and/or if a query to a
physician is necessary
- Queries physicians within established timelines via approved
query forms for conflicting, imprecise, incomplete, illegible, or
inconsistent documentation
- Uses clinical judgement to determine appropriate and relevant
clinical indicators and/or reasonable diagnostic options when
formulating patient-specific queries
- Assesses queries to determine if there is a thorough physician
response, subsequent documentation exists and the query can be
withdrawn, or if the query should be reassigned
- Engages with physicians in query follow up in a clear and
concise manner through iMobile, email, or text
- Develops and maintains collaborative relationships with
hospitalist medical directors, intensivists medical directors,
Chief of Staffs, Chief Medical Officers, and of physicians' private
practice Managers when unanswered queries need to be elevated
Strategic Relationships:
- Develops and strengthens collaborative relationships with
stakeholders to advance the care of our patients
- Actively encourages collaboration and possesses excellent
interpersonal skills in building and maintaining crucial
relationships
- Delivers information in a clear, concise and compelling manner
to effectively engage physicians
- Delivers targeted and actionable communications that invites
two way professional communication Adjust messages appropriately by
audience
- Demonstrates a willingness and ability to assist others
Self-Development:
- Demonstrates proficiency in current and emerging
technologies
- Simultaneously uses multiple technologies to complete unique
patient-level reviews
- Independently takes proactive steps toward problem
resolution
- Completes all mandatory and assigned education by established
deadlines
- Attends scheduled meetings and continuing education programs
Education & Experience:
- Bachelor's degree Required
- 3+ years of experience in an acute care facility Required Or
equivalent combination of education and/or experience Licenses,
Certifications, & Training
- RN License , Registered Health Information Admin (RHIA),
Registered Health Information Tech (RHIT), Certified Coding
Specialist, or Certified Clinical Documentation Specialist
Preferred
- Certified Documentation Improvement Professional Preferred HCA
Healthcare (Corporate), based in Nashville, Tennessee, supports a
variety of corporate roles from business operations to
administrative positions. Like our colleagues in any HCA Healthcare
hospital, our corporate campus employees enjoy
unparalleledresources and opportunitiesto reach their potential as
healthcare leaders and innovators. From market rate compensation to
continuing education andcareer advancement opportunities, every
person has a solid foundation for success. Nashville is also home
to ourExecutive Development Program, where exceptional employees
are groomed to take on CNO- and COO-level roles in our hospitals.
This selective program focuses on ethics, leadership and the
financial and clinical knowledge required of professionals at this
level of the industry.HCA Healthcare has been recognized as one of
the World's Most Ethical Companies by the Ethisphere Institute more
than ten times. In recent years, HCA Healthcare spent an estimated
$3.7 billion in cost for the delivery of charitable care, uninsured
discounts, and other uncompensated expenses."Good people beget good
people."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder We are a family 270,000 dedicated
professionals! Our Talent Acquisition team is reviewing
applications for our Remote Clinical Documentation Specialist
opening. Qualified candidates will be contacted for interviews.
Submit your resume today to join our community of caring!We are an
equal opportunity employer and value diversity at our company. We
do not discriminate on the basis of race, religion, color, national
origin, gender, sexual orientation, age, marital status, veteran
status, or disability status.
Keywords: HCA Healthcare, Fort Lauderdale , Clinical Documentation Specialist, Healthcare , Fort Lauderdale, Florida
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