Hartford HealthCare · 6 hours ago
Clinical Documentation Specialist
Vernon, CT
Full-time
Onsite
Mid, Senior Level
3+ years expHartford HealthCare is Connecticut’s most comprehensive healthcare network, and they are seeking a Clinical Documentation Specialist to support the quality of medical record documentation in their home health and hospice agency. The role involves ensuring the accuracy and completeness of clinical documentation, compliance with regulatory requirements, and collaboration with staff to improve documentation quality.
Health CareHealth DiagnosticsHospitalOncologyPharmaceuticalRehabilitation
Responsibilities
Examination of clinical documentation through extensive review of the clinical record with a particular focus on SOC/ROC/Re-certs, discharge and all OASIS documentation
Ensures clinical documentation is complete and accurate and demonstrates the provision of skilled services
Completes medical record review of patient records in a timely fashion to permit successful OASIS submission
Collaborates with quality/education staff to identify opportunities for improvement in documentation for quality reporting and report based on trends identified through review of documentation to ensure continued improvement
Stays current with OASIS guidelines, CMS regulations and other agency directives including knowledge of ICD-10-CM coding
Provide support to ensure that clinical information and quality data utilized in profiling and reporting is complete and accurate
Is a positive contributor in how documentation will affect quality outcomes in a timely manner
Collaborate on state and federal audit requests with quality team
Identifies issues requiring clarification or additional information in the clinical documentation and initiates communication with the appropriate care provider using the established processes
Maintains an open and collaborative working relationship with agency staff
Participates in team meetings to discuss cases, questions and performance improvement strategies
Assists in other monitoring activities, special department projects or other needs as determined by the Agency Director and/or the Director of Clinical Optimization
Works closely with the Director to ensure the performance of the Clinical Support Specialist and the duties contained within that role meet expectations
Ultimately responsible for the readiness of the claim for final release to billing
The CDS must exercise independent judgment, critical thinking, ability to work independently while following CMS guidelines, organizational policies, and procedures
Qualification
Required
A Registered Nurse or Physical Therapist licensed in the State
Experience in documentation review; OASIS certification preferred and working knowledge of ICD-10 coding guidelines is beneficial
Experience working in home health and hospice agency setting for 3 or more years; 5 years is a plus
Experience with clinical documentation integrity and reportable quality data measures
Must be highly detail oriented
Exceptional analytical and critical thinking skills
Excellent written and verbal communication and interpersonal skills
Must have superior organizational and time management skills
Must have excellent computer skills
Knowledge of accepted quality assurance procedures
Knowledge of patient privacy laws
Preferred
OASIS certification
Benefits
Competitive benefits program designed to ensure work/life balance
Company
Hartford HealthCare
Hartford HealthCare is a group of hospitals that offers complete healthcare services including cancer care, rehabilitation and pharmacy.
10001+ employees
H1B Sponsorship
Hartford HealthCare has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (7)
2024 (2)
2023 (4)
2022 (6)
2021 (4)
2020 (8)
Funding
Current Stage
Late StageTotal Funding
$150MKey Investors
Connecticut Health and Educational Facilities Authority
2024-04-01Debt Financing· $150M
Leadership Team
Jeffrey Flaks
President & Chief Executive Officer
Bimal Patel
President and COO
Recent News
Hartford Business Journal
2025-12-18
Company data provided by crunchbase