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Clinical Documentation Specialist

Augusta, Georgia
Job Type
19 May 2023

Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a(an) Clinical Documentation Reconciliation Specialist today with Doctors Hospital of Augusta.


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

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 free 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.
Free counseling services and resources for emotional, physical and financial wellbeing

401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)

Employee Stock Purchase Plan with 10% off HCA Healthcare stock

Family support through fertility and family building benefits with Progyny and adoption assistance.

Referral services for child, elder and pet care, home and auto repair, event planning and more

Consumer discounts through Abenity and Consumer Discounts

Retirement readiness, rollover assistance 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)

Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

Come join our team as a Clinical Documentation Specialist. We care for our community! Just last year, HCA Healthcare and our colleagues donated $13.8 million dollars to charitable organizations. Apply Today!

Job Summary and Qualifications

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.

Major Responsibilities:

Assessment of Documentation in Iodine:

Performs high priority initial concurrent review and re-reviews of clinically indicated conditions or procedures supported by the appropriate assignment of severity of illness, expected risk of mortality, intensity of service and resource consumption, which in turn accurately portrays quality outcomes ratings, reduces 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 insure 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 judgement, 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 judgement 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, intensivists medical directors, Chief of Staffs, Chief Medical Officers, and of 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 invites two way professional communication Adjust messages appropriately by audience
Demonstrates a willingness and ability to assist others


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:

Registered Nurse - Currently licensed as a Registered Professional Nurse in the state of residence required
Certified Clinical Documentation Specialist or
Documentation Improvement Practitioner or
Registered Health Information Administrator or
Registered Health Information Technician or
Certified Coding Specialist or
Certified Inpatient Coder or
Certified Professional Coder

This role requires you to be fully vaccinated for COVID-19 based on local, state and /or federal law or regulations (unless a medical or religious exemption is approved).

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 unparalleledresources and opportunitiesto reach their potential as healthcare leaders and innovators. From market rate compensation to continuing education andcareer advancement opportunities, every person has a solid foundation for success. Nashville is also home to ourExecutive 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 recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. 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.

"The great hospitals will always put the patient and the patient's family first, and the really great institutions will provide care with warmth, compassion, and dignity for the individual."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder

If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Clinical Documentation Reconciliation Specialist opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!

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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  • Job Reference: 1010174070-2
  • Date Posted: 19 May 2023
  • Recruiter: Doctors Hospital of Augusta
  • Location: Augusta, Georgia
  • Salary: On Application
  • Sector: Healthcare & Medical
  • Job Type: Permanent