CDS Trainee

Responsibilities

• Conduct 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.
• Collaborate closely with the medical staff to facilitate appropriate clinical documentation of patient care.
• Conduct documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and document findings.
• Additional duties as assigned.

Qualifications

• Medical Graduate, PA or Nursing Graduate.
• Minimum of six (6) months of clinical experience in an acute care setting in any capacity.
• 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.