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Clinical Documentation Spec 1 / HIM Fairfield SSO

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, 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 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.


The Clinical 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 provider 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 documentation clarifications/queries.
  • Meets program quality and productivity guidelines and standards.
  • Participates in Coding/CDI 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 Indicators (PSI)


  • 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.



  • 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
  • RN and/or CCS Coding Certification required
  • Certified Clinical Documentation Specialist (CCDS) certification or Certified Clinical Documentation Professional (CDIP) certification preferred


  • 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 skills

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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