Clinical Documentation Specialist (RN)
Company: HCA Houston Healthcare Mainland
Location: Texas City
Posted on: March 15, 2020
SHIFT: No Weekends
Do you have the career opportunities you want in
your current role? We have an exciting opportunity for you to join
largest provider of healthcare services as a Clinical Documentation
We offer you an
excellent total compensation package, including competitive salary,
benefit package and growth opportunities. We believe in our team
ability to do excellent work with us. Your benefits include 401k,
dental, flex spending, life, disability, tuition reimbursement,
discount program, employee stock purchase program and student loan
We would love to talk to you about this fantastic opportunity.
Houston Healthcare Mainland - Texas City, TX
Documentation Specialist (RN)
Founded in 1952, HCA Houston
Healthcare Mainland has been part of Galveston County for more than
Originally a 90-bed hospital, we have grown to a 223 bed acute care
offering quality, compassionate care with state-of-the-art
services. Our services
include inpatient and outpatient medical, surgical and specialty
What you will do in this
--- Reflects HCA's mission and values. Maintains sensitivity and
commitment to HCA's ethics and compliance principles (Code of
Conduct) in his/her daily activities/conduct.
--- Maintains and protects confidentiality.
--- Reviews medical records and identifies potential gaps in
clinical documentation for specified facilities, patient types and
payer populations, as directed on admission and throughout the
--- Performs initial concurrent review of assigned population
consistent with Facility, Division, or Corporate program volume and
--- Performs follow-up reviews consistent with Facility, Division
or Corporate program volume frequency requirements.
--- Assigns working DRG based upon identification and selection of
principal diagnosis, complications or co-morbid conditions and/or
valid OR procedures, including capture of POA indicators.
--- Ensures documented conditions, clarifications, and coded
diagnoses are clinically supported.
--- Documents reviews and other pertinent information in designated
systems by established deadlines.
--- Uses clinical judgement to determine when and/or if a query is
--- Queries physicians within established timelines via approved
query forms for conflicting, imprecise, incomplete, illegible, or
inconsistent documentation by requesting and obtaining additional
documentation within the health record when appropriate.
--- Uses clinical judgement to determine appropriate and relevant
clinical indicators and to discern appropriate reasonable
diagnostic options when formulating non-standard queries.
--- Interacts with Physicians to complete/resolve queries prior to
--- Collaborates with the Parallon HSC to assure accurate DRG
assignment and billing.
--- Performs reconciliation of CDI-assigned DRG against final coded
--- Escalates DRG mismatches as appropriate per established
--- Develops collaborative relationships to facilitate
accomplishment of work goals.
--- Possesses excellent interpersonal skills in building,
negotiating, and maintaining crucial relationships.
--- Demonstrates a willingness and ability to assist others.
--- Uses critical thinking skills and independent discretion to
analyze and interpret query trends/responses and to identify other
--- Compiles, creates and delivers education to physicians and
other key healthcare providers.
--- Provides ad hoc education upon request.
--- Demonstrates knowledge of Official Coding Guidelines and the
DRG Classification System to insure compliance with such
regulations as they relate to the CDI function.
--- Achieves and maintains a minimum accuracy rate consistent with
Facility, Division, or Corporate program requirements.
--- Participates in the analysis and trending of statistical data
to identify opportunities for improvement.
--- Assists with the preparation and presentation of clinical
documentation monitoring/trending reports for review with hospital
and medical staff leadership.
--- Represents the CDI function in other facility
--- Demonstrates proficiency in current and emerging
--- Completes all mandatory and assigned education by established
--- Attends scheduled meetings and continuing education
--- Seeks learning opportunities in areas of self-defined
--- Independently takes prompt proactive steps toward problem
qualifications you will need:
--- Associates Degree in Nursing required, BSN preferred
--- 5-7 years in Case Management, Quality Review and/or other
related clinical experience in an acute care environment
--- Current RN license required
--- Critical Care, ER, or OR experience preferred
HCA Healthcare ranks on Fortune's list of Most Admired
for three consecutive years and HCA ranks 63rd on the fortune 500
addition Ethisphere named HCA as one of the World's Most Ethical
want you to join our tradition of excellence. Intrigued? We'd love
to hear from
If you find this opportunity compelling, we encourage you to
apply. We promptly review all applications. If you are highly
will hear from the Talent Acquisition team.
We are actively interviewing so apply today!
We are an equal opportunity employer and value diversity at our
company. We do not discriminate on the basis of race, religion,
origin, gender, sexual orientation, age, marital status, veteran
Our Company's recruiters are here to help unlock the next
possibility within your career and we take your candidate
experience very seriously. During the recruitment process, no
recruiter or employee will request financial or personal
information (Social Security Number, credit card or bank
information, etc.) from you via email. The recruiters will not
email you from a public webmail client like Gmail or Yahoo Mail. If
you feel suspicious of a job posting or job-related email, let us
know by clicking here.
For questions about your job application or this site please
contact HCAhrAnswers at 1-844-422-5627 option 1.
Keywords: HCA Houston Healthcare Mainland, Texas City , Clinical Documentation Specialist (RN), Healthcare , Texas City, Texas
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