Clinical Documentation Spec 1 / HIM Clinical Document Mgmt

Hartford Healthcare • Farmington, CT

13d

About The Position

The Clinical Documentation Specialist (CDS) 1 conducts extensive medical record reviews and works with physicians, HIM coding professionals, nursing staff, and other patient care providers to support accurate representation of patient severity of illness and quality of care. The role participates in team meetings and helps develop clinical documentation guidelines and educate staff on them. Experienced CDS 1 staff may mentor or train other CDS employees during orientation and provide ongoing assistance with CDI policies, procedures, standard work, and systems.

The position is part of Hartford HealthCare’s System Support Office, which supports responsibilities and practices across the healthcare system. The role reports to the HHC Clinical Documentation Manager or Supervisor and may participate in additional assignments and special projects.

Requirements

• Associate degree or equivalent experience.
• Registered Nurse with at least 5 years of recent clinical experience in an acute care hospital, ICU, CCU, strong Med/Surg, or equivalent setting.
• Active RN license in the state of Connecticut.
• Strong written and verbal communication skills.
• Ability to learn or develop skills needed to conduct clinical documentation reviews of medical records.
• Knowledge of pathophysiology and disease processes, and working knowledge of clinical information.
• Ability to understand and communicate the impact of CC/MCCs and other variables on DRG methodology assignment.
• Ability to function independently.
• Solid analytical capabilities, strong organizational skills, and strong critical-thinking, problem-solving, and deductive-reasoning skills.
• Ability to handle multiple priorities and increasing responsibility.
• Ability to listen attentively to others’ ideas and expressions, communicate clearly using appropriate verbal and written communication and positive body language, collaborate toward common goals, and influence others toward positive and productive outcomes.

Nice To Haves

• Registered Nurse with 8 or more years of clinical experience in an acute care hospital, ICU, CCU, strong Med/Surg, or equivalent setting.
• Two or more years of experience as a Clinical Documentation Specialist.
• Certified Clinical Documentation Specialist (CCDS) certification.
• Certified Clinical Documentation Professional (CDIP) certification.

Responsibilities

• Review medical records extensively and accurately within specified timelines.
• Identify opportunities to improve documentation supporting severity of illness and quality of care, and formulate clinically credible documentation clarifications or queries.
• Follow up on cases, especially those involving documentation clarifications or queries, and educate providers on query responses and other CDI topics.
• Meet program quality, productivity, revenue-cycle, and KPI standards.
• Participate in Coding/CDI meetings and the CDI H3W work group.
• Enter review workflows, accurate data, and CDI query impact into Optum and EPIC.
• Collaborate with inpatient coders on appropriate DRGs and ICD-10 code assignments for compliance, reimbursement, and quality outcomes.
• Work with Coding and Quality Management teams to identify and develop compliant queries regarding Hospital Acquired Conditions and Patient Safety Indicators.
• Seek clarification from physicians, nursing staff, and other staff when documentation is absent, ambiguous, or contradictory.
• Collaborate with HIM coding staff to resolve discrepancies.
• Participate in team meetings and contribute to development of clinical documentation guidelines and ongoing staff education.
• When experienced, assist with training and mentoring new CDS staff on internal policies, procedures, standard work, and workflows.
• Follow the Ethical Standards for Clinical Documentation Improvement Professionals established by AHIMA.
• Complete other assignments and special projects as assigned.

Benefits

• Competitive benefits program designed to support work/life balance.
• Career development and growth opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree