Clinical Documentation Spec 1 / HIM Clinical Document Mgmt

Clinical Documentation Specialist (CDS) 1

Work where every moment matters. Every day, more than 40,000 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.

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 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 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 on an ongoing basis.

Position Responsibilities:

Key Areas of Responsibility

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 then 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

• An experienced CDS 1 may assist in training and mentoring new CDS' to become acclimated to new environment, and understanding internal policies, procedures, standard work, and workflows.

Communication

• Seeks clarification from physicians, nursing, and other staff in cases where 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.

This Job Reports To: HHC Clinical Documentation Manager or Supervisor

Qualifications

Education

• Associates Degree or equivalent experience.

Experience

• Minimum: Registered nurse (RN) with minimum of 5 years recent clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), strong Med/Surg. or equivalent
• Preferred: Registered Nurse (RN) with 8+ year's clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), strong Med/Surg. or equivalent
• 2 + years' 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/develop the skills necessary to perform Clinical Documentation review of medical records.
• Knowledge of Pathophysiology and Disease Process.
• Working knowledge of clinical information.
• Ability to understand and communicate the impact of CC/MCC's and other variables on the assignment of the various DRG methodologies.
• Must be able 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 ability to listen to and acknowledge ideas and expressions of others attentively.
• Strong ability to converse clearly using appropriate verbal and written communications as well as conveying 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.