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Clinical Documentation Specialist-Highlands RMC

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Fort Lauderdale, FL, United States

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SHIFT: No Weekends

SCHEDULE: Full-time

Clinical Documentation Specialist  Full Time
Highlands Regional Medical Center
Sebring, FL


Highlands Regional Medical Center

Sebring, FL

Facility Description:

Highlands Regional Medical Center, located in Sebring, FL is a 126-bed inpatient, full service facility offering a full range of Emergency, Surgical, Inpatient and Outpatient services. Highlands Regional Medical Center offers the most advanced technology and attracts the most highly qualified physicians and surgeons in our area. Serving the surrounding counties with all the expertise and compassion at its command, Highlands Regional Medical Center has cared for the citizens of Highlands and its surrounding counties since 1965. As we grow, the hospital is becoming more and more important to the people throughout this area.


Expertly staffed and equipped, this full-service hospital provides the proper environment essential for patient progress and ultimate recovery. Highlands Regional Medical Center's personnel, consisting of highly trained professionals, form a dedicated healthcare team whose coordinated efforts assure consistent excellence in various medical specialties. Highlands Regional's modern facility is designed to meet the diversity of its patients’ needs, from emergency care, to outpatient care, to surgery.


We offer a generous compensation package for Full-time and Part-time including: vacation, 401k, and Medical Insurance.

Job Description:

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.  



  • Bachelor degree in Health Information Management, Medicine or Nursing required. BS degree preferred.
  • Current RN license required with Critical Care, OR, ER experience preferred; or RHIA/RHIT/CCS certification required; or MBBS required.
  • 5 yrs. experience in Inpatient Coding/HIM, Case Management, Quality Review and/or other related clinical experience in an acute care facility preferred.


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.

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Facility: HCA Healthcare
Job ID: 25502-6513
Category: Case Management
Contract: Full-time
Shift: No Weekends
Job Class: Regular

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