CDS - Medical Records

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 offering a broad range of services including cardiovascular services, a comprehensive cancer care program, and centers of excellence for maternal-child health and outpatient behavioral health services. As the only hospital in Passaic, St. Mary's employs over 550 physicians and 1,000 staff, making it one of the largest employers in the county. The hospital is a member of Prime Healthcare, recognized as a "Top 15 Healthcare System" by Truven Health Analytics.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate whether clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services.
• Work closely with medical staff to facilitate appropriate clinical documentation of patient care.
• Conduct documentation for inpatient admission criteria and perform initial and extended-stay concurrent reviews on all selected admissions.
• Document findings and perform other duties as assigned or required.

Requirements

• Medical Graduate, Physician Assistant (PA), or Nursing Graduate required.
• Minimum of one (1+) year of clinical experience in an acute care setting.
• Knowledge of care delivery documentation systems and related medical record documents.
• Understanding of age-specific needs and 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, as well as critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nursing staff, and hospital management.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.

Qualifications

• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire; maintaining current certification preferred.
• ACLS Certificate preferred.

Benefits

• Comprehensive benefits package with flexibility to tailor benefits to individual needs.
• Paid time off.
• 401K retirement plan.
• Medical, dental, and vision coverage.
• Tuition reimbursement.
• Additional voluntary benefit options.

Pay

A reasonable compensation estimate for this role is $28.00 to $43.40 per hour. The exact starting compensation will be determined based on factors such as skillset, years of applicable experience, education, credentials, and licensure.

Schedule

• Full Time
• Day Shift