HCA, Hospital Corporation of America Clinical Documentation Improvement (CDI) Specialist, Lead in Jacksonville, Florida

Memorial Hospital (an HCA facility) is located less than 20 miles from the beaches of Jacksonville. We are the premiere medical facility in the Jacksonville area featuring a Certified Chest Pain Center, Certified Stroke Center as well as a dedicated Heart Center. Memorial Hospital is also a U.S. News and World Report Best Hospital.

We are looking for a new Lead Clinical Document Specialist, to work very closely with our Director of Quality and Risk, leading our team of three CDI Specialists, with the following duties and responsibilities:

  • Facilitating and obtaining appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient - Having proficiency regarding clinical documentation requirements, DRG assignment, and clinical conditions or procedures

    • Educating members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management

    • Performing quality assurance functions for CDI team, prepares and delivers education as appropriate, and monitors, trends, and educates as needed.

    • Completing initial reviews of patient records within 24–48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet

  • Conducting follow-up reviews of patients every 2–3 days or as appropriate to support and assign a working or final DRG assignment upon patient discharge
  • Querying physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when appropriate
  • Educating physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record

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

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

  • Assisting with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis

    • Partnering with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality

    • Reviewing and clarifying clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality

  • Performing quality review audits of CDI team

  • Preparing and presenting educational as identified via the CDI QA process Monitors and trends performance of CDI Specialists and recommends performance improvement steps/education as appropriate

Required Education:

Required License/Certification:

Required Experience:

Nursing or Health Information Management College Degree


1-3 years

Preferred Education:

Preferred License/Certification:

Preferred Experience:



Clinical Documentation Improvement, Coding, Clinical Chart Review

Special or additional competencies or qualifications:


Title: Clinical Documentation Improvement (CDI) Specialist, Lead

Location: Florida-Jacksonville-Memorial Hospital of Jacksonville

Requisition ID: 02525-10312