Clinical Documentation Specialist

HCA Reston , VA 20190

Posted 5 months ago

Healthcare Corporation of America (HCA) is a community of 94,000 Registered Nurses and 38,000 active physicians. We have over 1,900 facilities ranging from hospitals, freestanding ER's, ambulatory surgery centers, and urgent care clinics. Our facility based staff continues to raise the bar in patient care. Ten HCA hospitals have been named in IBM Watson Health's top 100 best-performing hospitals based on patient satisfaction and operational data.

Located in the outskirts of Washington, D.C, Reston Hospital Center, a 199-bed acute facility, lies within the vibrant Town Center of Reston, known for its lively mix of restaurants, shops, and services. Reston Hospital Center is an HCA (Hospital Corporation of America) facility making it a very secure and reputable facility to work with. HCA is one of the largest healthcare systems throughout the U.S, where healthcare employment opportunities are almost endless!

Reston Hospital Center holds certifications within our stroke and total joint center and is accredited in the chest pain center. Most importantly, Reston Hospital Center is dedicated to enhancing the health and quality of life in our community by putting patients first.

Our patients are our priority, but so are you!

Not only do our patients come first, but our employees do too! We provide a total compensation package to make sure your needs are met. Choose the medical coverage package that best suits you. Look after your loved ones while still getting paid with our Paid Family Leave. Plan for your future with our matching 401k or opt-in for several other benefits including tuition assistance, student loan repayment, family and medical flex spending accounts, life insurance, and identity theft protection.

HCA is dedicated to the growth and development of our colleagues. We will provide you the tools and resources you need to succeed in our organization. We are currently looking for an ambitious Clinical Documentation Specialist to help us reach our goals. Unlock your potential here!

Job Functions

  • Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, and other patient caregivers to ensure that the documentation of the level of service rendered to the patient and the patient's clinical complexity is complete and accurate.

  • Reviews medical records and identifies potential gaps in clinical documentation for specified patient types (e.g., I/P, O/P, etc.) and payer populations (e.g., Medicare, Medicaid, Blue Cross/Blue Shield, etc) as directed on admission and through hospitalization.

  • Performs initial concurrent review of assigned population consistent with Facility, Division or Company program volume and frequency requirements.

  • Performs follow-up reviews consistent with Facility, Division or Company program volume and frequency requirements.

  • Performs follow-up reviews consistent with Facility, Division or Company program requirements.

  • Achieves and maintains a minimum accuracy rate consistent with Facility, Division or Company program requirements.

  • Queries physicians and other caregivers as necessary via approved documented communication mechanisms regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed to obtain accurate and complete documentation that supports the severity of patient illness and risk of mortality.

  • Works closely with coding staff to assure documentation of discharge diagnoses and any co-existing comorbidities are a complete reflection of the patient's clinical status and care.

  • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.

  • Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.

  • Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

  • Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.

  • Demonstrates high level knowledge of coding standards and application to ongoing evaluation of medical record documentation.

  • Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.

  • Facilitates change processes required to capture appropriate documentation, such as forms redesign.

  • Other duties as assigned.


Education: 2 or 4 year undergraduate degree in Health Information Management, Nursing or health care related field strongly preferred. Equivalent work experience may substitute degree requirement.


License: RHIA, RHIT, CCS, RN or LPN required.

Experience: Minimum 3-5 years recent health information management, case management/utilization/ quality review and/or other related clinical experience in an acute care facility required. Knowledge base of ICD-9-CM coding and understanding of Diagnostic Related Groups (DRGs) strongly preferred.


As needed by the Department of Quality Resources to ensure proper operations.

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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Clinical Documentation Specialist