Clinical Documentation Spec 1 / HIM Clinical Document Mgmt

Hartford HealthCare; Farmington (CT); On-site; USD 70,000 - 90,000; Part time

Job summary

Hartford HealthCare is seeking a Clinical Documentation Specialist (CDS) 1 located in Farmington, CT. The CDS will perform extensive reviews of medical records and collaborate with healthcare professionals to ensure accurate clinical documentation.

Responsibilities include mentoring new CDS, training staff, and ensuring compliance with documentation standards. A minimum of 5 years experience as an RN in an acute care setting is required, with strong communication and analytical skills highly valued. Join a dynamic team focused on improving patient care.

Qualifications

• Registered Nurse (RN) with minimum of 5 years recent clinical experience in an acute care hospital.
• 2+ years of experience as a Clinical Documentation Specialist (CDS).
• Licensed RN in the state of CT.

Responsibilities

• Provides extensive and accurate reviews of medical records within specified timelines.
• Assists in training and mentoring new Clinical Documentation Specialists.
• Collaborates with HIM coding staff to resolve discrepancies.

Skills

Strong communication skills

Analytical capabilities

Critical thinking

Organizational skills

Education

Associates Degree or equivalent experience

Job description

Location Detail: 9 Farm Springs Rd Farmington (10566)

Shift Detail: per diem

Position Summary

The Clinical Documentation Specialist (CDS) 1 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 also participates actively in team meetings and develops clinical documentation guidelines and educates staff on these guidelines on an ongoing basis. CDS 1 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.

Position Responsibilities

• Documentation Review
  • Provides extensive and accurate reviews of medical records within specified timelines.
  • Recognizes opportunities for documentation improvement to support severity of illness and quality of care and formulates clinically credible documentation clarifications/queries.
  • Follows up on all cases, especially those with clinical documentation clarifications/queries; provides education to providers on responding to queries in the medical record and other CDI topics.
  • Meets program quality and productivity guidelines and standards.
  • Participates in Coding/CDI meetings and CDI H3W work group.
  • Inputs review workflows and accurate data and CDI query impact into Optum and EPIC.
  • Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups (MS-DRG, APR-DRGs, etc.) and ICD-10 code assignment for compliance, reimbursement, and quality outcomes.
  • Works with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI).
  • Meets revenue cycle goals, Key Performance Indicators (KPIs), quality and productivity standards.
• Training & Special Projects
  • Assists in training and mentoring new CDS to become acclimated to the environment, and to understand internal policies, procedures, standard work, and workflows.
• Communication
  • Seeks clarification from physicians, nursing, and other staff when documentation is absent, ambiguous, or contradictory.
  • Collaborates with HIM coding staff to resolve discrepancies.
• Other
  • Abides by The Ethical Standards for Clinical Documentation Improvement (CDI) Professionals as set forth by the American Health Information Management Association.
  • Participates in other assignments and special projects as assigned.

Qualifications

• Education
  • Associates Degree or equivalent experience.
• Experience
  • Minimum: Registered Nurse (RN) with minimum of 5 years recent clinical experience in an acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), or strong Med/Surg; or equivalent.
  • Preferred: Registered Nurse (RN) with 8+ years of clinical experience in an acute care hospital, ICU, CCU, or strong Med/Surg; or equivalent.
  • 2+ years of experience as a CDS.
• Licensure, Certification, Registration
  • Minimum: RN licensed in the state of CT.
  • Preferred: Certified Clinical Documentation Specialist (CCDS) certification or Certified Clinical Documentation Professional (CDIP) certification.
• Language Skills
  • Strong written and verbal communication skills.
• Knowledge, Skills and Ability Requirements
  • Ability to learn and develop the skills necessary to perform Clinical Documentation review of medical records.
  • Knowledge of pathophysiology and disease process.
  • Working knowledge of clinical information.
  • Understanding and communication of the impact of CC/MCC’s and other variables on the assignment of the various DRG methodologies.
  • Ability to function independently.
  • Solid analytical capabilities.
  • Strong organizational skills.
  • Strong critical thinking, problem solving, and deductive reasoning skills.
  • Ability to handle multiple priorities and increasing responsibility.
  • Strong listening skills and ability to acknowledge ideas and expressions of others attentively.
  • Strong communication skills in both verbal and written forms, including positive body language.
  • Ability to collaborate with others to achieve a common goal through mutual cooperation.
  • Ability to influence others for positive and productive outcomes.

Working Relationships

This Job Reports To: HHC Clinical Documentation Manager or Supervisor