CDS Trainee - HMC Medical Records

Overview

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Harlingen 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.

 

Harlingen Medical Center is a Level IV Trauma Designated hospital that specializes in Cardiovascular Service, Emergency Services, Neuroscience, Orthopedic Services, Radiology, Rehabilitation Services and Surgical Services. Harlingen Medical Center has provided high-quality “Patient Focused Care” to the residents of Western Cameron County for more than 15 years. Harlingen Medical Center, one of South Texas’s best kept secrets, offers patients the best of both worlds--a warm, caring environment, close to home while providing the wide range of services and expertise typically found in much larger facilities.

 

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

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 and Work ExperienceRequired 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.