CDS Trainee - SMHP Medical Records

Prime Healthcare•Passaic, NJ

About The Position

The CDS Trainee conducts clinically based concurrent and retrospective reviews of inpatient medical records to evaluate whether clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services. The role collaborates closely with medical staff to facilitate appropriate clinical documentation of patient care. Additional duties include documenting inpatient admission criteria, conducting initial and extended-stay concurrent reviews on selected admissions, and documenting findings. Other duties may be assigned.

Requirements

Medical graduate, PA graduate, or nursing graduate.
At least six 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, disease processes, and related procedures.
Broad-based clinical knowledge and understanding of the pathology and physiology of disease processes.
Excellent written and verbal communication skills and critical-thinking skills.
Interpersonal skills to build effective working relationships with physicians, nursing 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 basic office equipment.
Assertive personality traits to facilitate ongoing physician communication.

Nice To Haves

Working knowledge of the Medicare reimbursement system and coding structures.

Responsibilities

Conduct concurrent and retrospective reviews of inpatient medical records.
Evaluate whether clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services.
Collaborate with medical staff to facilitate appropriate clinical documentation of patient care.
Conduct documentation for inpatient admission criteria.
Perform initial and extended-stay concurrent reviews on selected admissions and document findings.
Perform additional duties as assigned.