Clinical Documentation Specialist

HCA Healthcare
November 17, 2022
United States
Job Type
Work Setting


Do you want to join an organization that invests in you as a Clinical Documentation Specialist? At HCA Healthcare, you come first. HCA Healthcare has committed up to $300 million in programs to support our incredible team members over the course of three years.


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

  • 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 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.
  • Fertility and family building benefits through Progyny
  • Free counseling services and resources for emotional, physical, and financial wellbeing
  • Family support, including adoption assistance, child and elder care resources, and consumer discounts
  • 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
  • Employee Stock Purchase Plan
  • Retirement readiness and rollover 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)

Note: Eligibility for benefits may vary by location.

You contribute to our success. Every role has an impact on our patient's lives, and you have the opportunity to make a difference. We are looking for a dedicated Clinical Documentation Specialist like you to be a part of our team.

Job Summary and Qualifications

Clinical Documentation Specialist

*This role will be onsite at HCA Florida Raulerson Hospital in Okeechobee, FL, with occasional travel to HCA Florida Highlands Hospital in Sebring, FL*

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.

  • Performs high-priority initial concurrent review and re-reviews of clinically indicated conditions or procedures supported by the appropriate assignment of the severity of illness, expected risk of mortality, the intensity of service, and resource consumption, which in turn accurately portrays quality outcomes ratings, reduce 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 ensure 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 judgment, 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 judgment 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, intensivist medical directors, Chief of Staffs, Chief Medical Officers, and 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 invite two way professional communication Adjust messages appropriately by the 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
  •  RN License, Registered Health Information Admin (RHIA), Registered Health Information Tech (RHIT), Certified Coding Specialist, or Certified Clinical Documentation Specialist Preferred
  •  Certified Documentation Improvement Professional Preferred
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