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Clinical Documentation Spec 1 / HIM Clinical Document Mgmt

Requisition ID:


Business Unit:

Hartford HealthCare Corp.


Newington, CT

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Job Schedule: Full Time
Standard Hours: 40
Job Shift: Shift 1
Shift Details:

Work where every moment matters. 

Every day, over 30,000 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 Connecticut’s 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 the 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.

Position Responsibilities:

Documentation Review:

  • Provides extensive and accurate reviews of medical records within specified timelines.
  • Recognizes opportunities for documentation improvement to support severity of illness and quality of care and then formulates clinically credible documentation clarifications/queries.
  • Follows up on all cases especially those with clinical documentation clarifications/queries.
  • Meets program quality and productivity guidelines and standards.
  • Participates in Coding/CDI Task Force Meetings.
  • Inputs data into Optum.
  • Collaborates with inpatient coders to determine appropriate Medicare Severity-Diagnosis Related Groups (MS-DRG, APR-DRGs, etc.) assignment for compliance and reimbursement purposes.
  • Works with Coding and Quality Management teams to appropriately identify Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI).
  • Meets revenue cycle goals (Key Performance Indicators (KPIs) and Productivity Standards).


  • Seeks clarification from physicians, nursing, and other staff in cases where documentation is absent, ambiguous, or contradictory.
  • Communicates with HIM coding staff to resolve discrepancies


  • Abides by The Ethical Standards for Clinical Documentation Improvement (CDI) Professionals as set forth by the American Health Information Management Association.
  • Participates in other assignments and special projects as assigned.

Working Relationships:

Job Title of Individual(s) Reports To:  HHC Clinical Documentation Manager or Supervisor


Requirements and Specifications:

Education: Associates Degree or equivalent experience


  • Registered nurse (RN) with recent clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), or strong Med/Surg.or
  • Certified Coding professional with 1-2 years CDS experience

Minimum License, Certification, Registration:

  • RN and/or Certified Coding Specialist (CCS)

Preferred License, Certification, Registration:

  • Certified Clinical Documentation Specialist (CCDS) certification or
  • Certified Clinical Documentation Professional (CDIP) certification

Language Skills: strong written and verbal communication skills

Knowledge, Skills, and Ability Requirements:

  • Ability to learn/develop the skills necessary to perform Clinical Documentation review of clinical documentation.
  • Ability to understand and communicate the impact of CC/MCC’s and other variables on the assignment of the various DRG methodologies.
  • Must be able to function independently.
  • Solid analytical capabilities.
  • Strong organizational skills.
  • Strong critical thinking, problem solving and deductive reasoning skills.
  • Ability to handle multiple priorities and increasing responsibility
  • Strong ability to listen to and acknowledge ideas and expressions of others attentively.
  • Strong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body language.
  • Ability to collaborate with others to achieve a common goal through mutual cooperation.
  • 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 – 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.

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