CDS Trainee - SMNJ Medical Records FAC#2

Overview

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Saint Michael's Medical Center, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

 

Established by the Franciscan Sisters of the Poor in 1867, Saint Michael's Medical Center is a 358-bed regional tertiary-care, teaching, and research center in the heart of Newark's business and educational district and is accredited by The Joint Commission. Combining state-of-the-art technology, the latest diagnostic and therapeutic procedures, leading-edge research, and a network of highly qualified physicians, nurses, and allied health professionals, the hospital provides top-quality health care services delivered with compassionate care.

 

The first medical institution in New Jersey to perform open-heart surgery, and the first to develop a cardiac catheterization program, Saint Michael's Medical Center is home to the Heart and Vascular Institute, which offers a comprehensive array of innovative cardiac treatments and procedures. Learn more at www.smmcnj.com.

 

We are an Equal Opportunity Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation, or other protected characteristics.  If you need special accommodation for the application process, please contact Human Resources.  Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

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.

Qualifications

Education and Work Experience

Medical Graduate or RN required

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.

Working knowledge of Medicare reimbursement system and coding structures preferred.