CDS Trainee - Medical Records

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

 

Responsibilities

CDS Trainee is responsible 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:

 

1.    Medical Graduate, PA, or Nursing Graduate.

2.    Minimum of six (6) months of clinical experience in an acute care setting in any capacity.

3.    Knowledge of care delivery documentation systems and related medical record documents.

4.    Knowledge of age-specific needs and the elements of disease processes and related procedures.

5.    Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.

6.    Excellent written and verbal communication skills. Excellent critical thinking skills.

7.    Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.

 

Preferred qualifications:

 

1.    Working knowledge of inpatient admission criteria.

2.    Ability to work independently in a time-oriented environment.

3.    Computer literacy and familiarity with the operation of basic office equipment.

4.    Assertive personality traits to facilitate ongoing physician communication.

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

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf