Job Schedule: Full Time Standard Hours: 40 Job Shift: Shift 1 Shift Details:
Work where every
Every day, almost 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
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.
Documentation Specialist (CDS) 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.
Accurate and timely medical record review.
Recognizes opportunities for documentation improvement to
support severity of illness and quality of care and then formulates clinically
credible documentation clarifications/queries.
Timely follow up on all cases especially those with clinical
Meets program quality and productivity guidelines and
Participates in Coding/CDI Task Force Meetings.
Accurate input of data into EPIC and Optum 360 CAC CDI
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
Seeks clarification from physicians, nursing, and
other staff in cases where documentation is absent, ambiguous, or
Communicates with HIM coding staff to resolve discrepancies
by The Ethical Standards for Clinical Documentation Improvement (CDI)
Professionals as set forth by the American Health Information Management
EDUCATION and/or EXPERIENCE REQUIRED
Registered Nurse (RN) required, Bachelors Science
Nursing (BSN) preferred, with recent hospital experience preferably Intensive
Care Unit (ICU), Cardiac Care Unit (CCU), or strong Med/Surg.
Certified Coding professional with 1-2 years CDS experience
LICENSE and/or CERTIFICATION
RN and/or CCS Coding Certification required
Certified Clinical Documentation Specialist
(CCDS) certification or Certified Clinical Documentation Professional (CDIP)
Knowledge of Pathophysiology and Disease Process
Microsoft Office Products; Word, Excel, Powerpoint
Strong written and verbal communication skills.
Solid analytical capabilities.
Good organizational skills.
Critical thinking, problem solving and deductive reasoning
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
Handle multiple priorities and increasing responsibility
Listen and acknowledge ideas and expressions of others
Converse clearly using appropriate verbal and body language.
Collaborate with others to achieve a common goal through
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.