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Trinity Health Clinical Documentation & Coding Specialist in Ft. Lauderdale, Florida

Holy Cross Hospital in Fort Lauderdale, Florida is a full-service, non-profit Catholic hospital, sponsored by the Sisters of Mercy and a member of Trinity Health.

Clinical Documentation Medical Record Review

  • Utilizes paper or electronic tools and reports to identify and prioritize case reviews, follow-up reviews and outstanding queries.
  • Utilizes critical thinking skills to perform concurrent review of clinical documentation in the medical record.
  • Analyzes the patient s current clinical status, treatment plan and past medical history to identify potential gaps in physician documentation.
  • Identifies the principal diagnosis and all secondary conditions, co-morbidities, complications and procedures that have been documented in the medical record.
  • Evaluates anchor visit for each diagnosis that could potentially affect risk score calculation.
  • Queries the physician, mid-level clinicians and other clinicians for clarification and to obtain accurate and complete documentation as needed, based on current clinical findings, prescribed treatment, medical interventions and/or procedures.
  • Follow commercial and governmental coding regulations as determined by payer
  • Adheres to AHIMA guidelines for effective, compliant query writing.
  • Regular queries to Claims and Clinical data and appropriate follow-up interventions
  • Applies knowledge/skills regarding coding conventions, coding guidelines and coding clinics when reviewing the medical record.
  • Adheres to the Clinical Documentation programs established work flow and processes.
  • Performs retrospective medical record reviews, as requested.
  • Access claims and clinical data to identify high and low network performers
  • Focus on commercial products, may assist with Medicare Advantage preparation and planning
  • Interact with IT teams from each participating organization to understand and identify EHR capabilities and coding tools for HCC and MRA coding


Interdisciplinary Communication & Relationships

  • Works collaboratively with the coding professionals to obtain documentation of diagnoses, co-morbidities and procedures which results in a complete and accurate reflection of the patients clinical status and care.
  • Consults with coding professionals as needed, for clarification regarding coding convention and guidelines.
  • Works collaboratively with the Medical Director when escalation of cases is required, and to develop and implement ongoing physician education programs.
  • Collaborates with physicians, mid-level residents/interns, mid-level clinicians and other clinicians to accurately identify principal diagnosis options, secondary diagnoses and procedures.
  • Serves as a resource to physicians, mid-level clinicians and other clinicians regarding clinical documentation, severity of illness and risk of mortality.
  • Approaches and responds to conflict in a constructive manner, with a focus on problem solving for a collaborative solution/resolution.
  • Provides formal and informal feedback and training to physicians, mid-level clinicians and other clinicians with respect to clinical documentation excellence and the impact of documentation on coding accuracy, healthcare profiling and correct reimbursement.
  • Work collaboratively with subnetwork documentation and coding specialists


Data Management and Reconciliation Process

  • Demonstrates competency with utilization of all necessary software and information systems necessary to conduct clinical documentation activities.
  • Self-monitors performance data though weekly reports.
  • Identifies opportunities during reconciliation process for second-level review and follows up with coding professionals to make sure appropriate documentation is present for accurate coding.
  • Generate and present appropriate reports as requested
  • Interprets data monitoring reports and identifies areas of focus for documentation improvement through analysis of monthly data.
  • Maintains professional integrity and confidentiality of information in accordance with applicable policies, procedures, state and federal requirements.
  • Assist with departmental policy review, revision and development. Assist with identifying workflow and modification of same to improve efficiencies.

Minimum Requirements

  • Associates Degree required.
  • BSN preferred with 5 years of acute care nursing experience, or, in lieu of a nursing degree, a Bachelor's degree in Health Information Management or a related field and five 3 to 5 years of inpatient coding experience; Or Foreign Medical Graduate with 3 to 5 years of experience generally obtained from Clinical rounding, clinical shadowing or previously worked as Clinical Documentation Specialist.
  • Experience in Utilization Management/Case Management, Critical Care, and patient outcomes/quality management preferred; Experience in delivering education to diverse group of people and able to understand and deliver clinical terms with physicians and unit nurses; Experience with databases, spreadsheet software and presentation software preferred; Experience working with EPIC, Optum and CDIS. Able to understand and analyze reports.


Job Number: 00058803

Location: Ft. Lauderdale, FL

Organization Name: Holy Cross Hospital

Facility: HCHFL - Holy Cross Hospital

Employment Type: Full time

Shift: Day Shift

Hours: 40