CDS Trainee

St. Clare's - Denville•Denville, NJ

About The Position

At Saint Clare's Health, our dedicated team of professionals is committed to our core values of quality, compassion, and community. As a member of Prime Healthcare, Saint Clare's Health is actively seeking new members to join its award-winning team! Saint Clare's Health includes CMS 5-Star Rated hospitals and is an award-winning provider of safe, high quality, compassionate care, serving the communities of Morris, Warren and Sussex counties. Its network of hospitals and healthcare facilities include Denville Hospital, Dover Hospital, Behavioral Health Centers in Boonton, Denville, and Parsippany, and an Imaging Center in Parsippany, among other satellite locations. The hospitals have received multiple quality awards including Leapfrog “A” ratings for patient safety; Healthgrades recognition for orthopedic surgery, treatment of stroke, heart care, various surgical procedures, and more. For information, visit www.saintclares.com. CDS Trainee is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation is reflective of quality-of-care outcomes and reimbursement compliance for acute care services provided. CDS Trainee will collaborate closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. Additional duties as assigned.

Requirements

Medical Graduate, PA or Nursing Graduate required.
Minimum of six (6) months of clinical experience in an acute care setting in any capacity.
Knowledge of care delivery documentation systems and related medical record documents.
Knowledge of age-specific needs and the elements of disease processes and related procedures.
Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
Excellent written and verbal communication skills. Excellent critical thinking skills.
Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.
Working knowledge of inpatient admission criteria.
Ability to work independently in a time-oriented environment.
Computer literacy and familiarity with the operation of basic office equipment.
Assertive personality traits to facilitate ongoing physician communication.

Nice To Haves

Working knowledge of Medicare reimbursement system and coding structures preferred.

Responsibilities

conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation is reflective of quality-of-care outcomes and reimbursement compliance for acute care services provided
collaborate closely with the medical staff to facilitate appropriate clinical documentation of patient care
conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings
Additional duties as assigned