RN / Case Management / Texas / Permanent / Clinical Documentation Specialist (RN) Job
Location: Texas City
Posted on: March 20, 2020
Description SHIFT: No Weekends
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
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
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
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
- Performsinitial concurrent review of assigned population
consistent with Facility,Division, or Corporate program volume and
- 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
- 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
- Collaborateswith the Parallon HSC to assure accurate DRG
assignment and billing.
- Performsreconciliation of CDI-assigned DRG against final coded
- EscalatesDRG mismatches as appropriate per established
- 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
- Compiles,creates and delivers education to physicians and other
- 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
- Demonstratesproficiency in current and emerging
- Completesall mandatory and assigned education by established
- Attendsscheduled meetings and continuing education
- Seekslearning opportunities in areas of self-defined
- Independentlytakes prompt proactive steps toward problem
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
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