Clinical Documentation Specialist in Nashville, Tennessee, United States
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Clinical Documentation Specialist

Work from Home
Nashville, TN, United States
Full-time • Work From Home
Information Technology   Job ID: 30864
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Do you want to join an organization that invests in you as a(an) Clinical Documentation Specialist? At Work from Home, 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.


At Work from Home, we want to ensure your needs are met. We offer eligible colleagues an attractive benefit package that includes medical, wellbeing, dental and vision benefits along with some unique benefits including:

  • Medical, Dental, Vision, Life Insurance and Flexible Spending
  • Paid Time Off (PTO) and Personal Leave
  • 401K (100% annual match - 3% to 9% of pay based on years of service)
  • Academic Assistance and Reimbursements for Tuition and Student Loans
  • Employee Discounts including Tickets, Retail, Mental Health Apps, Education Apps, Identity Theft Protection etc.
  • HomeAuto, and Pet Insurance
  • Employee Stock Purchase Program (ESPP)
  • Short Term Long Term Disability coverage
  • Adoption Assistance
  • Legal Benefits and lots more!

Learn more about Employee Benefits

You contribute to our success. Every role has an impact on our patients’ 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

The Clinical Documentation Reconciliation Specialist conducts a comprehensive retrospective review of clinical documentation within the medical record, CDI or Forecast DRG, and final coded DRG, to assure accurate DRG assignment. As appropriate, the Clinical Documentation Reconciliation Specialist may initiate a review by the HSC.
The Clinical Documentation Reconciliation Specialist must be a subject matter expert in Clinical Documentation and will adhere to process standardization to promote improved outcomes, maximize resource utilization, and improve organizational efficiencies.

Assessment of Documentation:

  • Performs high priority retrospective reviews of the complete medical record and the coding summary of assigned population.
  • Analyzes documented and clinically supported conditions in multiple electronic health record technologies to ensure complete documentation.
  • Performs independent coding of the record to assure that the HIM coding accurately reflects the documentation.
  • Ensures documented conditions, clarifications, and coded diagnoses are clinically supported.
  •  Working and Target DRGs that accurately reflect expected CDI query impact.

  • Demonstrates knowledge of Official Coding Guidelines and the DRG Classification System to insure regulatory compliance related to the CDI and coding functions.
  • Identifies and documents education opportunities for CDI Specialists
  • Thoroughly documents reviews and other pertinent information in designated systems by established deadlines.
  • Achieves and maintains key operating metrics consistent with CDI Reconciliation program requirements.
  • ·Using critical thinking skills, independent discretion, clinical judgement, Official Coding Guidelines, DRG Classification, and Coding Clinics determines when and/or if escalation to the HSC is necessary.

  • Escalates DRG mismatches with coding opportunities as appropriate per established protocols.Monitors and documents HSC responses.
  • ·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 facilitate accomplishment of work goals

  • Delivers targeted and actionable communications that invites two-way professional communication. Adjusts messages appropriately by audience Demonstrates a willingness and ability to assist others

  • Education & Qualifications

  • Bachelors Degree
  • 5yrs experience in acute CDI
  • Registered Nurse - Currently licensed as a registered professional nurse OR

    Reg Health Information Admin OR

    Reg Health Information Tech OR

  • Certified Coding Specialist

    Cert Clinical Doc Spec, preferred

    Certified Documentation Improvement Professional, preferred

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 unparalleled resources and opportunities to reach their potential as healthcare leaders and innovators. From market rate compensation to continuing education and career advancement opportunities, every person has a solid foundation for success. Nashville is also home to our Executive 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 named one of the World's Most Ethical Companies by Ethisphere Institute for over a decade.  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.

"Good people beget good people."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder

We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Documentation Specialist opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring!

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.


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Information Technology
Work from Home
Full-time • Work From Home

About HCA Healthcare

What matters most to our diverse and talented colleagues is giving people the absolute best healthcare in the most compassionate way possible.

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