CDS - Medical Records

Prime Healthcare•Passaic, NJ

1d•Onsite

About The Position

St. Mary's General Hospital, located in Passaic, NJ, is a community-based tertiary medical center focused on providing quality, compassionate care. It is an acute care hospital providing a broad range of services including cardiovascular services as well as a comprehensive program for cancer care. The hospital is also a center of excellence for maternal-child health and outpatient behavioral health services. It is the only hospital in Passaic and with over 550 physicians and 1,000 employees, and is one of the largest employers in the county. Every member of the St. Mary's General team is committed to providing respectful, personalized, high-quality care. St. Mary's General Hospital is a member of Prime Healthcare, which has been lauded as a "Top 15 Healthcare System" by Truven Health Analytics. For information, visit www.smh-nj.com .

Requirements

Medical Graduate, PA or Nursing Graduate required
Minimum of three one (1+) years clinical experience in an acute care setting
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 and 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

ECFMG Certificate or RN license preferred.
Prior Case Management Experience preferred.
Working knowledge of the Medicare reimbursement system and coding structures preferred.
Current BCLS (AHA) certificate upon hire and maintain current preferred.
ACLS Certificate preferred.

Responsibilities

Conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided.
Working 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.
Performing other duties as assigned or required.