Job Schedule: Full Time Standard Hours: 40 Job Shift: Shift 1 Shift Details:
Work where every moment
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
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.
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 staff on these guidelines on an ongoing basis.
Accurate and timely medical
Recognizes opportunities for
documentation improvement to support severity of illness and quality of
care and then formulates clinically credible documentation
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 Task
Accurate input of data into
Collaborates with inpatient
coders to determine appropriate Medicare Severity-Diagnosis Related Groups
(MS-DRG, APR-DRGs, etc.) assignment for compliance and reimbursement
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
License and/or Certification Required:
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
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 attentively.
Converse clearly using appropriate verbal and body language.
Collaborate with others to achieve a common goal through mutual cooperation.
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 isyour moment.