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queries to determine if there is a thorough physician response, subsequent documentation exists and the query can be withdrawn, or if the query should be reassigned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