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Clinical Documentation Specialist 1

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 35,000 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 Inpatient 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 documentation for accurate representation of the severity of illness and quality of care of the patient. The CDS is also expected to have active participation in team meetings and education of clinicians on clinical documentation requirements.



Job functions

  • Accurate and timely medical record review in the outpatient, inpatient, and post-acute care areas.
  • 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/Department Meetings as appropriate.
  • Accurate input of data into EPIC and Optum 360 CAC CDI.
  • Collaborates with inpatient coders to determine appropriate specificity of all diagnoses, and 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)
  • Appropriately identifies Hierarchal Condition Categories (HCC) codes and seeks clarification as needed.
  • Maintains reports as appropriate and provides action planning and provider education for identified clinical documentation opportunities.


  • Seeks clarification from physicians, nursing, and other staff in cases where documentation is absent, ambiguous, non-specified, 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


  • 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, HCC’s, and other variables on the assignment of the various DRG methodologies, SOI/ROM, and quality outcomes.
  • Function independently
  • 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 is your moment.

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