Work where every moment mattersEvery day approximately 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 Connecticutrsquos most comprehensive healthcare networkThe 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 organizationWith 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 systemPosition SummaryThe 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 patient severity of illness and quality of careThe 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 basisCDS may mentor train or lead other CDS during their orientation period and assist them with Clinical Documentation Integrity CDI policies procedures standard work and systems on an ongoing basisPosition ResponsibilitiesKey Areas of ResponsibilityDocumentation ReviewmiddotProvides extensive and accurate reviews of medical records within specified timelinesmiddotRecognizes opportunities for documentation improvement to support severity of illness and quality of care and then formulates clinically credible documentation clarificationsqueriesmiddotFollows up on all cases especially those with clinical documentation clarificationsqueries Provides education to providers on responding to queries in the medical record and other CDI topicsmiddotMeets program quality and productivity guidelines and standardsmiddotParticipates in CodingCDI meetings and CDI HW work groupmiddotInputs review workflows and accurate data and CDI query impact into Optum and EPICmiddotCollaborates with inpatient coders to determine appropriate Diagnosis Related Groups MS DRG APR DRGs etc and ICD code assignment for compliance reimbursement and quality outcomesmiddotWorks with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions HAC and Patient Safety Indicators PSImiddotMeets revenue cycle goals Key Performance Indicators KPIs quality andproductivity standardsTraining Special ProjectsmiddotAn experienced CDS may assist in training and mentoring new CDSrsquo to become acclimated to new environment and understanding internal policies procedures standard work and workflowsCommunicationmiddotSeeks clarification from physicians nursing and other staff in cases where documentation is absent ambiguous or contradictorymiddotCollaborates with HIM coding staff to resolve discrepanciesOthermiddotAbides by The Ethical Standards for Clinical Documentation Improvement CDI Professionals as set forth by the American Health Information Management AssociationmiddotParticipates in other assignments and special projects as assignedWorking RelationshipsJob Title of Individuals Reports ToHHC Clinical Documentation Manager or SupervisorWork where every moment mattersEvery day approximately 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 Connecticutrsquos most comprehensive healthcare networkThe 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 organizationWith 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 systemPosition SummaryThe 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 patient severity of illness and quality of careThe 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 basisCDS may mentor train or lead other CDS during their orientation period and assist them with Clinical Documentation Integrity CDI policies procedures standard work and systems on an ongoing basisPosition ResponsibilitiesKey Areas of ResponsibilityDocumentation ReviewmiddotProvides extensive and accurate reviews of medical records within specified timelinesmiddotRecognizes opportunities for documentation improvement to support severity of illness and quality of care and then formulates clinically credible documentation clarificationsqueriesmiddotFollows up on all cases especially those with clinical documentation clarificationsqueries Provides education to providers on responding to queries in the medical record and other CDI topicsmiddotMeets program quality and productivity guidelines and standardsmiddotParticipates in CodingCDI meetings and CDI HW work groupmiddotInputs review workflows and accurate data and CDI query impact into Optum and EPICmiddotCollaborates with inpatient coders to determine appropriate Diagnosis Related Groups MS DRG APR DRGs etc and ICD code assignment for compliance reimbursement and quality outcomesmiddotWorks with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions HAC and Patient Safety Indicators PSImiddotMeets revenue cycle goals Key Performance Indicators KPIs quality andproductivity standardsTraining Special ProjectsmiddotAn experienced CDS may assist in training and mentoring new CDSrsquo to become acclimated to new environment and understanding internal policies procedures standard work and workflowsCommunicationmiddotSeeks clarification from physicians nursing and other staff in cases where documentation is absent ambiguous or contradictorymiddotCollaborates with HIM coding staff to resolve discrepanciesOthermiddotAbides by The Ethical Standards for Clinical Documentation Improvement CDI Professionals as set forth by the American Health Information Management AssociationmiddotParticipates in other assignments and special projects as assignedWorking RelationshipsJob Title of Individuals Reports ToHHC Clinical Documentation Manager or SupervisorEducationmiddotAssociates Degree or equivalent experienceExperiencemiddotRegistered nurse RN with recent clinical experience in acute care hospital Intensive Care Unit ICU Cardiac Care Unit CCU or strong MedSurgormiddotCertified Coding professional with years CDS experienceLicensure Certification RegistrationmiddotMinimum RN andor Certified Coding Specialist CCSmiddotPreferred Certified Clinical Documentation Specialist CCDS certificationormiddotCertified Clinical Documentation Professional CDIP certificationLanguage SkillsmiddotStrong written and verbal communication skillsKnowledge Skills and Ability RequirementsmiddotAbility to learndevelop the skills necessary to perform Clinical Documentation review of medical recordsmiddotKnowledge of Pathophysiology and Disease ProcessmiddotWorking knowledge of clinical informationmiddotAbility to understand and communicate the impact of CCMCCrsquos and other variables on the assignment of the various DRG methodologiesmiddotMust be able to function independentlymiddotSolid analytical capabilitiesmiddotStrong organizational skillsmiddotStrong critical thinking problem solving and deductive reasoning skillsmiddotAbility to handle multiple priorities and increasing responsibilitymiddotStrong ability to listen to and acknowledge ideas and expressions of others attentivelymiddotStrong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body languagemiddotAbility to collaborate with others to achieve a common goal through mutual cooperationmiddotAbility to influence others for positive and productive outcomesWe take great care of careersWith 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 ndash 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 worklife balance Every moment matters And this isyour momentEducationmiddotAssociates Degree or equivalent experienceExperiencemiddotRegistered nurse RN with recent clinical experience in acute care hospital Intensive Care Unit ICU Cardiac Care Unit CCU or strong MedSurgormiddotCertified Coding professional with years CDS experienceLicensure Certification RegistrationmiddotMinimum RN andor Certified Coding Specialist CCSmiddotPreferred Certified Clinical Documentation Specialist CCDS certificationormiddotCertified Clinical Documentation Professional CDIP certificationLanguage SkillsmiddotStrong written and verbal communication skillsKnowledge Skills and Ability RequirementsmiddotAbility to learndevelop the skills necessary to perform Clinical Documentation review of medical recordsmiddotKnowledge of Pathophysiology and Disease ProcessmiddotWorking knowledge of clinical informationmiddotAbility to understand and communicate the impact of CCMCCrsquos and other variables on the assignment of the various DRG methodologiesmiddotMust be able to function independentlymiddotSolid analytical capabilitiesmiddotStrong organizational skillsmiddotStrong critical thinking problem solving and deductive reasoning skillsmiddotAbility to handle multiple priorities and increasing responsibilitymiddotStrong ability to listen to and acknowledge ideas and expressions of others attentivelymiddotStrong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body languagemiddotAbility to collaborate with others to achieve a common goal through mutual cooperationmiddotAbility to influence others for positive and productive outcomesWe take great care of careersWith 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 ndash 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 worklife balance Every moment matters And this isyour moment