**Please note this is not a remote position**

Introduction

Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a Clinical Documentation Specialist today with HCA Florida West Hospital.

Benefits

HCA Florida West Hospital offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
• Free counseling services and resources for emotional, physical and financial wellbeing
  
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
  
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock
  
• Family support through fertility and family building benefits with Progyny and adoption assistance.
  
• Referral services for child, elder and pet care, home and auto repair, event planning and more
  
• Consumer discounts through Abenity and Consumer Discounts
  
• Retirement readiness, rollover assistance services and preferred banking partnerships
  
• Education assistance (tuition, student loan, certification support, dependent scholarships)
  
• Colleague recognition program
  
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
  
• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

Come join our team as a Clinical Documentation Specialist. We care for our community! Just last year, HCA Healthcare and our colleagues donated $13.8 million dollars to charitable organizations. Apply Today!

Job Summary and Qualifications

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.

Major Responsibilities:

Assessment of Documentation in Iodine:

• 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:

• Registered Nurse - Currently licensed as a Registered Professional Nurse in the state of residence or
• Certified Clinical Documentation Specialist or
• Documentation Improvement Practitioner or
• Registered Health Information Administrator or
• Registered Health Information Technician or
• Certified Coding Specialist or
• Certified Inpatient Coder or
• Certified Professional Coder required

This role requires you to be fully vaccinated for COVID-19 based on local, state and /or federal law or regulations (unless a medical or religious exemption is approved).

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.

"The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder

If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Clinical Documentation Specialist opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and 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.