CDS Trainee - SCDNNJ Medical Records Fac#01

Prime Healthcare•Denville, NJ

13d

About The Position

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.

Requirements

Medical Graduate, PA or Nursing Graduate.
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.
Collaborating 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.