RN / Case Management / Texas / Permanent / Clinical Documentation Specialist (RN) Job

Company: HCA.
Location: Texas City
Posted on: March 20, 2020

Job Description:

Description SHIFT: No Weekends

SCHEDULE: Full-time

Do you have the career opportunities you want inyour current role? We have an exciting opportunity for you to join the nation'slargest provider of healthcare services as a Clinical Documentation Specialist(RN).
We offer you anexcellent total compensation package, including competitive salary, excellentbenefit package and growth opportunities. We believe in our team and yourability to do excellent work with us. Your benefits include 401k, PTO medical,dental, flex spending, life, disability, tuition reimbursement, employeediscount program, employee stock purchase program and student loan repayment.We would love to talk to you about this fantastic opportunity.
HCAHouston Healthcare Mainland Texas City, TX ClinicalDocumentation Specialist (RN)
Founded in 1952, HCA HoustonHealthcare Mainland has been part of Galveston County for more than 55 years.Originally a 90-bed hospital, we have grown to a 223 bed acute care facilityoffering quality, compassionate care with state-of-the-art services. Our servicesinclude inpatient and outpatient medical, surgical and specialty services.
What you will do in thisrole:

• ReflectsHCAs mission and values. Maintains sensitivity and commitment to HCAs ethicsand compliance principles (Code of Conduct) in his/her dailyactivities/conduct.
• Maintainsand protects confidentiality.
• Reviewsmedical records and identifies potential gaps in clinical documentation forspecified facilities, patient types and payer populations, as directed onadmission and throughout the hospitalization.
• Performsinitial concurrent review of assigned population consistent with Facility,Division, or Corporate program volume and frequency requirements.
• Performsfollow-up reviews consistent with Facility, Division or Corporate programvolume frequency requirements.
• Assignsworking DRG based upon identification and selection of principal diagnosis,complications or co-morbid conditions and/or valid OR procedures, includingcapture of POA indicators.
• Ensuresdocumented conditions, clarifications, and coded diagnoses are clinicallysupported.
• Documentsreviews and other pertinent information in designated systems by establisheddeadlines.
• Usesclinical judgement to determine when and/or if a query is necessary.
• Queries physicianswithin established timelines via approved query forms for conflicting,imprecise, incomplete, illegible, or inconsistent documentation by requestingand obtaining additional documentation within the health record whenappropriate.
• Usesclinical judgement to determine appropriate and relevant clinical indicatorsand to discern appropriate reasonable diagnostic options when formulatingnon-standard queries.
• Interactswith Physicians to complete/resolve queries prior to patient discharge.
• Collaborateswith the Parallon HSC to assure accurate DRG assignment and billing.
• Performsreconciliation of CDI-assigned DRG against final coded DRG.
• EscalatesDRG mismatches as appropriate per established protocols.
• Developscollaborative relationships to facilitate accomplishment of work goals.
• Possessesexcellent interpersonal skills in building, negotiating, and maintainingcrucial relationships.
• Demonstratesa willingness and ability to assist others.
• Usescritical thinking skills and independent discretion to analyze and interpretquery trends/responses and to identify other education opportunities.
• Compiles,creates and delivers education to physicians and other key healthcareproviders.
• Provides adhoc education upon request.
• Demonstratesknowledge of Official Coding Guidelines and the DRG Classification System toinsure compliance with such regulations as they relate to the CDI function.
• Achievesand maintains a minimum accuracy rate consistent with Facility, Division, orCorporate program requirements.
• Participatesin the analysis and trending of statistical data to identify opportunities forimprovement.
• Assistswith the preparation and presentation of clinical documentationmonitoring/trending reports for review with hospital and medical staffleadership.
• Representsthe CDI function in other facility quality/monitoring activities.
• Demonstratesproficiency in current and emerging technologies.
• Completesall mandatory and assigned education by established deadlines.
• Attendsscheduled meetings and continuing education programs.
• Seekslearning opportunities in areas of self-defined needs.
• Independentlytakes prompt proactive steps toward problem resolution.
  Qualifications Whatqualifications you will need:
  • Associates Degree in Nursing required, BSNpreferred
  • 5-7 years in Case Management, Quality Reviewand/or other ...

Keywords: HCA., Texas City , RN / Case Management / Texas / Permanent / Clinical Documentation Specialist (RN) Job, Executive , Texas City, Texas