Clinical Documentation Spec 1 / HIM Clinical Document Mgmt

We need to output HTML fragment with sections: Use

for headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections if posting has real specific content. We have location detail, shift detail, summary, responsibilities, qualifications, etc. No explicit pay, schedule, benefits details (though mentions benefits program but not specifics). The instruction: never create Pay/Schedule/Benefits sections unless posting actually states them. It mentions "We provide a competitive benefits program designed to ensure work/life balance." That's a generic statement but still mentions benefits. However they said "Prefer a few substantive sections over many thin ones." Might include Benefits if there is some content. It says "competitive benefits program". That's not specific detail but still content. Might be considered substantive? The rule: never emit a heading followed by filler/placeholder text (e.g., "commensurate with experience", "not specified", "N/A", "varies", "TBD"). "competitive benefits program" is not filler but vague. Might still be okay. But safer to omit Benefits section because not specific. Similarly Pay and Schedule not mentioned. So we include About the role (position summary), Responsibilities, Qualifications (maybe combine Requirements and Qualifications?), Skills. The posting has "Qualifications Requirements and Specifications:" includes Education, Experience, Licensure, Certification, Language Skills. Also "Knowledge, Skills And Ability Requirements". So we can have sections: About the role (position summary), Responsibilities, Qualifications (education, experience, licensure, certification), Skills (knowledge, skills, abilities). Possibly also "Working Relationships" but not required heading. We'll stick to allowed headings. We need to preserve all substantive information. So include location detail and shift detail maybe in a paragraph under About the role? The location detail and shift detail are metadata; we can fold into a short

. The instruction: do NOT put Job ID/requisition numbers as headings — fold minor metadata into a short

or drop it. So we can include a paragraph with location and shift. We must not repeat job title as heading. The job title is Clinical Documentation Specialist (CDS) 1. Not to repeat as heading. We must remove boilerplate: cookie/navigation/legal/EEO etc. Not present. We must output only HTML fragment. Let's craft:

Location: 9 Farm Springs Rd, Farmington (10566). Shift: REMOTE position with monthly on‑site responsibilities in Connecticut.

Then

About the role

... position summary ...

Responsibilities:

Responsibilities

• ... each bullet ...

Qualifications:

Qualifications

maybe split into Education, Experience, Licensure/Certification, Language Skills. Could keep as list. Skills:

Skills

• ... knowledge, skills, abilities ...

We must not invent content. Ensure we capture all details. Let's extract details: Position Summary paragraph: "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." Responsibilities: Under "Position Responsibilities Key Areas of Responsibility Documentation Review" etc. Let's list each bullet: - 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. - Working Relationships: This Job Reports To: HHC Clinical Documentation Manager or Supervisor We could include Working Relationships as a bullet. 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: list many items. Let's capture them as bullet list under Skills. List: - 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. Also maybe include "We take great care of careers..." but that's more boilerplate; could be omitted as not specific. We'll not include Benefits/Pay/Schedule. Now produce HTML. Make sure to use

for each section heading. Use

for prose paragraphs. Use

• for lists. We'll have:

  Location: 9 Farm Springs Rd, Farmington (10566). Shift: REMOTE position with monthly on‑site responsibilities in Connecticut.

  About the role

  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.

  Responsibilities

  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • Experience (preferred): Registered Nurse (RN) with 8+ years’ 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 (minimum): RN licensed in the state of CT.
  • Licensure/Certification (preferred): Certified Clinical Documentation Specialist (CCDS) certification or Certified Clinical Documentation Professional (CDIP) certification.
  • Language Skills: Strong written and verbal communication skills.

  Skills

  • 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