HCA, Hospital Corporation of America Clinical Documentation DRG Specialist PRN in San Jose, California

_Schedule:_ 0.001 Per Diem,_Shift:_ Variable, as needed.

_Internal Posting Period:_ September 26, 2016 – October 3, 2016

Under general supervision, the Documentation Specialist (DS) conducts concurrent and retrospective review of the clinical documentation in the medical record to achieve more accurate and detailed documentation, which will in turn improve the quality of patient care, more accurately portray the facility’s quality outcomes ratings, reduce compliance risks, and capture appropriate reimbursement.**


Minimum knowledge, skills and abilities required:

1. Undergraduate degree required. 2. Current California License (RN) or CCS – Certified Coding Specialist required.*__* 3. Completes continuing education requirements as determined by licensing/credentialing body. 4. Superior clinical assessment skills 5. Knowledge of care delivery documentation systems and related medical record documents. 6. Working knowledge of reimbursement systems and coding structures strongly preferred. 7. Building and Maintaining Strategic Working Relationships – develops collaborative relationships to facilitate the accomplishment of work goals. Possesses excellent interpersonal skills in building, negotiating and maintaining crucial relationships. 8. Building Trust – interacts with others in a way that gives them confidence in one’s intentions and those of the organization. 9. Organization – proactively prioritizes initiatives, effectively manages resources and keen ability to multi-task. 10.Communication – communicates clearly, proactively and concisely with all key stakeholders. 11.Effective Operational Decision Making – relating and comparing; securing relevant information and identifying key issues; committing to an action after developing alternative courses of action that take into consideration resources, constraints, and organizational values. 12.Managing conflict – dealing effectively with others in antagonistic situations; using appropriate interpersonal styles and methods to reduce tension or conflict between two or more people. 13.Critical thinking – actively and skillfully conceptualizing, applying, analyzing, synthesizing or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning or communication as a guide to belief and action. 14.Demonstrates leadership attributes. 15.Strong organizational skills. 16.Adaptability – maintaining effectiveness when experiencing major changes in work tasks or the work environment; able to adapt to change in environment and/or circumstances with a positive outlook; and adjusting effectively to work within new work structures, processes, requirements, or cultures. 17.Energy – consistently maintaining high levels of activity or productivity; sustaining long working hours when necessary; operates with vigor, effectiveness, and determination over extended periods of time. 18.Initiative – independently takes prompt proactive steps towards problem resolution. 19.Customer orientation – establishes and maintains long-term customer relationships and ensures that the customer perspective is the driving force behind all value-added business activities. 20.Facilitation – ability to facilitate small to large groups of people at various organizational levels for purposes of planning, problem solving, or strategy development. 21.Negotiate and influence others – facilitates agreement in order to influence positive outcomes. 22.Policies & Procedures – articulate knowledge and understanding of organizational polices, procedures and systems. 23.PC skills – demonstrates proficiency in software applications as required.

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*Minimum Experience:*

1. Minimum 5 years recent case management/utilization/quality review and/or other related clinical experience in an acute care facility required. 2. Knowledge base of ICD-9-CM coding and understanding of Diagnostic Related Groups (DRGs) strongly preferred. 3. Ability to understand and follow verbal and written instructions. Must effectively read, write and verbally communicate in the English language.


  1. The Documentation Specialist is directly responsible to the Director of HIM. A collaborative relationship with other staff is maintained.
  2. Responsible for supervising, delegating and coordinating the work of other staff as assigned.
  3. Degree of supervision required: Minimal, individual proceeds on his/her own initiative, in compliance with policies, practices and procedures prescribed by professional nursing practice and approved by the hospital’s Operations Division.


Requires prolonged sitting, some bending, stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports. Requires lifting papers or boxes up to 25 pounds occasionally. Work is performed in an office environment. Work may be stressful at times. Contact may involve dealing with angry or upset people. Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergency situations. #LI-FW

Title: Clinical Documentation DRG Specialist PRN

Location: California-San Jose-Good Samaritan Hospital

Requisition ID: 03360-16652