Clinical Documentation Specialist (RN)

Company: HCA Houston Healthcare Mainland
Location: Texas City
Posted on: March 15, 2020

Job Description:

Description

SHIFT: No Weekends

SCHEDULE: Full-time

Do you have the career opportunities you want in
your current role? We have an exciting opportunity for you to join the nation's
largest provider of healthcare services as a Clinical Documentation Specialist
(RN).

We offer you an
excellent total compensation package, including competitive salary, excellent
benefit package and growth opportunities. We believe in our team and your
ability to do excellent work with us. Your benefits include 401k, PTO medical,
dental, flex spending, life, disability, tuition reimbursement, employee
discount program, employee stock purchase program and student loan repayment.
We would love to talk to you about this fantastic opportunity.

HCA
Houston Healthcare Mainland - Texas City, TX

Clinical
Documentation Specialist (RN)

Founded in 1952, HCA Houston
Healthcare 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 facility
offering quality, compassionate care with state-of-the-art services. Our services
include inpatient and outpatient medical, surgical and specialty services.

What you will do in this
role:

--- 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 hospitalization.
--- Performs initial concurrent review of assigned population consistent with Facility, Division, or Corporate program volume and frequency requirements.
--- 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 necessary.
--- 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 patient discharge.
--- Collaborates with the Parallon HSC to assure accurate DRG assignment and billing.
--- Performs reconciliation of CDI-assigned DRG against final coded DRG.
--- Escalates DRG mismatches as appropriate per established protocols.
--- 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 education opportunities.
--- 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 quality/monitoring activities.
--- Demonstrates proficiency in current and emerging technologies.
--- Completes all mandatory and assigned education by established deadlines.
--- Attends scheduled meetings and continuing education programs.
--- Seeks learning opportunities in areas of self-defined needs.
--- Independently takes prompt proactive steps toward problem resolution.

Qualifications

What
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 Companies
for three consecutive years and HCA ranks 63rd on the fortune 500 list. In
addition Ethisphere named HCA as one of the World's Most Ethical Companies. We
want you to join our tradition of excellence. Intrigued? We'd love to hear from
you.

If you find this opportunity compelling, we encourage you to
apply. We promptly review all applications. If you are highly qualified you
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, color, national
origin, gender, sexual orientation, age, marital status, veteran status, or
disability status.

Notice

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