Clinical Documentation Spec 1 / HIM Clinical Document ...

Work whereevery momentmatters. Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticutu2019s most comprehensive healthcare network. The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization. With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system. _Position Summary:_ The Clinical Documentation Specialist (CDS) 1 is responsible for extensive record review, and interaction with physicians, HIM coding professionals, nursing staff and other patient care givers to ensure the accurate representation of patient severity of illness and quality of care. The CDS is also responsible for active participation in team meetings and development of clinical documentation guidelines and education of staff on these guidelines on an ongoing basis. CDS 1 may mentor, train or lead other CDS during their orientation period and assist them with Clinical Documentation Integrity (CDI) policies, procedures, standard work, and systems on an ongoing basis. _Position Responsibilities:_ Key Areas of Responsibility Documentation Review u00b7 Provides extensive and accurate reviews of medical records within specified timelines. u00b7 Recognizes opportunities for documentation improvement to support severity of illness and quality of care and then formulates clinically credible documentation clarifications/queries. u00b7 Follows up on all cases especially those with clinical documentation clarifications/queries. Provides education to providers on responding to queries in the medical record and other CDI topics. u00b7 Meets program quality and productivity guidelines and standards. u00b7 Participates in Coding/CDI meetings and CDI H3W work group. u00b7 Inputs review workflows and accurate data and CDI query impact into Optum and EPIC. u00b7 Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups (MS-DRG, APR-DRGs, etc.) and ICD-10 code assignment for compliance, reimbursement, and quality outcomes. u00b7 Works with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI). u00b7 Meets revenue cycle goals, Key Performance Indicators (KPIs) , quality and productivity standards). Training & Special Projects u00b7 An experienced CDS 1 may assist in training and mentoring new CDSu2019 to become acclimated to new environment, and understanding internal policies, procedures, standard work, and workflows. Communication u00b7 Seeks clarification from physicians, nursing, and other staff in cases where documentation is absent, ambiguous, or contradictory. u00b7 Collaborates with HIM coding staff to resolve discrepancies. Other u00b7 Abides by The Ethical Standards for Clinical Documentation Improvement (CDI) Professionals as set forth by the American Health Information Management Association. u00b7 Participates in other assignments and special projects as assigned. _Working Relationships:_ This Job Reports To:HHC Clinical Documentation Manager or Supervisor Education u00b7 Associates Degree or equivalent experience. Experience u00b7 Registered nurse (RN) with recent clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), or strong Med/Surg. or u00b7 Certified Coding professional with 1-2 years CDS experience Licensure, Certification, Registration u00b7 Minimum: RN and/or Certified Coding Specialist (CCS) u00b7 Preferred: o Certified Clinical Documentation Specialist (CCDS) certification or o Certified Clinical Documentation Professional (CDIP) certification Language Skills u00b7 Strong written and verbal communication skills Knowledge, Skills and Ability Requirements: u00b7 Ability to learn/develop the skills necessary to perform Clinical Documentation review of medical records. u00b7 Knowledge of Pathophysiology and Disease Process. u00b7 Working knowledge of clinical information. u00b7 Ability to understand and communicate the impact of CC/MCCu2019s and other variables on the assignment of the various DRG methodologies. u00b7 Must be able to function independently. u00b7 Solid analytical capabilities. u00b7 Strong organizational skills. u00b7 Strong critical thinking, problem solving and deductive reasoning skills. u00b7 Ability to handle multiple priorities and increasing responsibility u00b7 Strong ability to listen to and acknowledge ideas and expressions of others attentively. u00b7 Strong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body language. u00b7 Ability to collaborate with others to achieve a common goal through mutual cooperation. u00b7 Ability to influence others for positive and productive outcomes. _We take great care of careers.___ With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge u2013 helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment. Job: Administrative Organization: Hartford HealthCare Corp. Title: Clinical Documentation Spec 1 / HIM Clinical Document Mgmt Location: Connecticut-Farmington-9 Farm Springs Rd Farmington (10566) Requisition ID: 25166382

Created: 2026-02-02