CDS Trainee - SMHP Medical Records

Overview

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 .

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Responsibilities

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 work 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 provided.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required Qualifications

• Medical Graduate, PA or Nursing Graduate.
• Minimum of 3 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. 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.
  
  

Preferred Qualifications

• Working knowledge of Medicare reimbursement system and coding structures preferred.