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.

 

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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 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. Additional duties as assigned.

Qualifications

EDUCATION, EXPERIENCE, TRAINING 1. Medical Graduate, PA or Nursing Graduate required. 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.8. Working knowledge of inpatient admission criteria. 9. Ability to work independently in a time-oriented environment. 10. Computer literacy and familiarity with the operation of basic office equipment. 11. Assertive personality traits to facilitate ongoing physician communication. 12. Working knowledge of Medicare reimbursement system and coding structures preferred.