Division Nursing Director Clinical Documentation Management

  • Company: Hospital Corporation of America
  • Location: Fort Lauderdale, Florida
  • Posted: July 13, 2017
  • Reference ID: 25502-5779
Division Nursing Director Clinical Documentation Management - Full time, Days
HCA East Florida Division
Fort Lauderdale, FL

With more than 18,000 of your neighbors, friends and colleagues, the East Florida Division of HCA is committed to building healthy communities in South Florida and the Treasure Coast. The core of our values emanates from our continued focus on improving the health and quality of life for residents in the communities we serve. To accomplish this we strive to identify top talent aligned with our values and dedicated to furthering our mission. With 14 hospitals to choose from, your possibilities for achievement, variety, and career growth are endless. We invite you to learn more about who we are and how you can join our dynamic team!

HCA East Florida Division is part 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!

Job Description:
Reporting to the Division Chief Financial Officer, the Division RN Director Clinical Documentation Management will be responsible for daily oversight of the staff involved in clinical documentation improvement (CDI). He or she will play a lead role in improving the overall integrity of medical record documentation. Through appropriate interactions with physicians, nursing staff, other patient caregivers, case managers and coding staff assists in obtaining modifications or additions in documentation to the medical record that supports accuracy and completeness of clinical information. The position is also responsible for complying with corporate policy and procedures, managing resources, and identifying and meeting customer needs in a team environment.

Responsibilities include:
  • Act as manager support for the staff positions for the department
  • Train and mentor new staff hired, including onsite assistance at request of Division CFO
  • Conduct onsite training and updates as needed to staff in all 4 markets and float to market based facility assignments as needed
  • Conduct initial and extended-stay concurrent review on selected inpatient admissions to assess for appropriate clinical documentation that reflects the services and procedures received by the patient
  • Document findings on current clinical documentation system on a daily basis
  • Identify co-morbidities/complications and obtains appropriate chart documentation from physicians to support these conditions
  • Obtain clarification of clinical documentation daily, querying the medical staff via written/verbal communication to obtain complete and accurate documentation, advocating for appropriate DRG assignment, for the patient care resources consumed and the level of service rendered
  • Utilize critical thinking skills to identify documentation issues such as quality, appropriateness, completeness and reimbursement issues and communicates these issues to physicians and other caregivers so that immediate resolution can be made in medical record documentation
  • Act a liaison for documentation efficiencies with Health Information Management, Case Management, Ancillary Departments, Physicians and Senior Management
  • Demonstrate knowledge of DRG payor issues, appropriate DRG assignment alternatives, and clinical documentation requirements
  • Conduct daily follow-up reviews of clinical documentations to ensure points of clarification have been recorded in the patient's charts
  • Review clinical issues when appropriate with coding staff to determine a working DRG and/or clarification of documentation as needed
  • Develop training materials and tools to conduct ongoing clinical documentation education sessions for physician and other hospital personnel
  • Identify documentation trends and issues for individual physicians and reports these to the Case management Director, HIM Director and/or Quality Director for any appropriate peer review follow up monthly

  • Registered Nurse with current Florida License required
  • More than 7 years hospital clinical experience with 2 years clinical chart review experience
  • Hospital or managed care case management, revenue integrity, or quality review experience preferred
  • Management experience
  • Bachelor's degree strongly preferred

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