HCA, Hospital Corporation of America Clinical Documentation Specialist, Full-Time, Northwest Medical Center in Fort Lauderdale, Florida

Clinical Documentation Specialist Full Time *

Northwest Medical Center Margate, FL

Facility Description: Join a dynamic team of healthcare providers in a friendly work environment. We are dedicated to the highest quality patient care and we are looking for dedicated, qualified, compassionate professionals to become part of our team. Northwest Medical Center offers supportive management, great benefits and flexibility. A 228-bed medical center, we continue to expand and integrate the latest technology into patient care.

Our facility features a state of the art Cardiovascular Tower, an expanded Emergency Room and newly added Level III NICU to provide comprehensive services to the community we serve and increased professional growth opportunity for our employees. / / /Northwest Medical Center is a member of the nation’s leading provider of healthcare services, Hospital Corporation of America. HCA has been named one of Ethisphere’s World’s Most Ethical Companies for eight consecutive years. Join our tradition of excellence!/ / / /Benefits:/ /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.

This position is located at Northwest Medical Center

Job: *Case Management

Title: Clinical Documentation Specialist, Full-Time, Northwest Medical Center

Location: Florida-Fort Lauderdale-East Florida Division Shared Services

Requisition ID: 25502-6689