Work where every moment mattersEvery day more than 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 system Position 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 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 CDS 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 basis Position ResponsibilitiesKey Areas of ResponsibilityDocumentation Reviewmiddot Provides extensive and accurate reviews of medical records within specified timelinesmiddot Recognizes opportunities for documentation improvement to support severity of illness and quality of care and then formulates clinically credible documentation clarificationsqueriesmiddot Follows 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 topicsmiddot Meets program quality and productivity guidelines and standardsmiddot Participates in CodingCDI meetings and CDI HW work groupmiddot Inputs review workflows and accurate data and CDI query impact into Optum and EPICmiddot Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups MS DRG APR DRGs etc and ICD code assignment for compliance reimbursement and quality outcomesmiddot Works with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions HAC and Patient Safety Indicators PSImiddot Meets revenue cycle goals Key Performance Indicators KPIs quality and productivity standardsTraining Special Projectsmiddot An experienced CDS may assist in training and mentoring new CDSrsquo to become acclimated to new environment and understanding internal policies procedures standard work and workflowsCommunicationmiddot Seeks clarification from physicians nursing and other staff in cases where documentation is absent ambiguous or contradictorymiddot Collaborates with HIM coding staff to resolve discrepanciesOthermiddot Abides by The Ethical Standards for Clinical Documentation Improvement CDI Professionals as set forth by the American Health Information Management Associationmiddot Participates in other assignments and special projects as assigned Working RelationshipsThis Job Reports To HHC Clinical Documentation Manager or SupervisorWork where every moment mattersEvery day more than 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 system Position 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 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 CDS 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 basis Position ResponsibilitiesKey Areas of ResponsibilityDocumentation Reviewmiddot Provides extensive and accurate reviews of medical records within specified timelinesmiddot Recognizes opportunities for documentation improvement to support severity of illness and quality of care and then formulates clinically credible documentation clarificationsqueriesmiddot Follows 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 topicsmiddot Meets program quality and productivity guidelines and standardsmiddot Participates in CodingCDI meetings and CDI HW work groupmiddot Inputs review workflows and accurate data and CDI query impact into Optum and EPICmiddot Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups MS DRG APR DRGs etc and ICD code assignment for compliance reimbursement and quality outcomesmiddot Works with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions HAC and Patient Safety Indicators PSImiddot Meets revenue cycle goals Key Performance Indicators KPIs quality and productivity standardsTraining Special Projectsmiddot An experienced CDS may assist in training and mentoring new CDSrsquo to become acclimated to new environment and understanding internal policies procedures standard work and workflowsCommunicationmiddot Seeks clarification from physicians nursing and other staff in cases where documentation is absent ambiguous or contradictorymiddot Collaborates with HIM coding staff to resolve discrepanciesOthermiddot Abides by The Ethical Standards for Clinical Documentation Improvement CDI Professionals as set forth by the American Health Information Management Associationmiddot Participates in other assignments and special projects as assigned Working RelationshipsThis Job Reports To HHC Clinical Documentation Manager or SupervisorEducationmiddot Associates Degree or equivalent experienceExperiencemiddot Registered nurse RN with recent clinical experience in acute care hospital Intensive Care Unit ICU Cardiac Care Unit CCU or strong MedSurgormiddot Certified Coding professional with years CDS experienceLicensure Certification Registrationmiddot Minimum RN andor Certified Coding Specialist CCSmiddot Preferredo Certified Clinical Documentation Specialist CCDS certificationoro Certified Clinical Documentation Professional CDIP certificationLanguage Skillsmiddot Strong written and verbal communication skillsKnowledge Skills and Ability Requirementsmiddot Ability to learndevelop the skills necessary to perform Clinical Documentation review of medical recordsmiddot Knowledge of Pathophysiology and Disease Processmiddot Working knowledge of clinical informationmiddot Ability to understand and communicate the impact of CCMCCrsquos and other variables on the assignment of the various DRG methodologiesmiddot Must be able to function independentlymiddot Solid analytical capabilitiesmiddot Strong organizational skillsmiddot Strong critical thinking problem solving and deductive reasoning skillsmiddot Ability to handle multiple priorities and increasing responsibilitymiddot Strong ability to listen to and acknowledge ideas and expressions of others attentivelymiddot Strong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body languagemiddot Ability to collaborate with others to achieve a common goal through mutual cooperationmiddot Ability to 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 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 Educationmiddot Associates Degree or equivalent experienceExperiencemiddot Registered nurse RN with recent clinical experience in acute care hospital Intensive Care Unit ICU Cardiac Care Unit CCU or strong MedSurgormiddot Certified Coding professional with years CDS experienceLicensure Certification Registrationmiddot Minimum RN andor Certified Coding Specialist CCSmiddot Preferredo Certified Clinical Documentation Specialist CCDS certificationoro Certified Clinical Documentation Professional CDIP certificationLanguage Skillsmiddot Strong written and verbal communication skillsKnowledge Skills and Ability Requirementsmiddot Ability to learndevelop the skills necessary to perform Clinical Documentation review of medical recordsmiddot Knowledge of Pathophysiology and Disease Processmiddot Working knowledge of clinical informationmiddot Ability to understand and communicate the impact of CCMCCrsquos and other variables on the assignment of the various DRG methodologiesmiddot Must be able to function independentlymiddot Solid analytical capabilitiesmiddot Strong organizational skillsmiddot Strong critical thinking problem solving and deductive reasoning skillsmiddot Ability to handle multiple priorities and increasing responsibilitymiddot Strong ability to listen to and acknowledge ideas and expressions of others attentivelymiddot Strong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body languagemiddot Ability to collaborate with others to achieve a common goal through mutual cooperationmiddot Ability to 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 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