Clinical Documentation Specialist (CDS) Trainee

Overview

At North Vista Hospital, our dedicated team of professionals are committed to our core values of quality, compassion, and community. As a member of Prime Healthcare, a Top-15 hospital system in the United States, North Vista Hospital is actively seeking new members to join its award-winning team! North Vista Hospital is an accredited 177-bed state-of-the-art hospital located in North Las Vegas, Nevada. North Vista offers comprehensive healthcare services, including mental health care, emergency care, heart care, advanced surgical procedures, diagnostic imaging and help for a broad range of medical conditions. Equipped with advanced medical technology and staffed by a team of highly skilled healthcare professionals, North Vista is committed to providing high-quality care in a friendly hospital environment. The hospital has achieved numerous quality award distinctions including Patient Safety Excellence Award, Bariatric Surgery Excellence Award, Heart Failure recognition and more.

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 documenting findings.
• Additional duties as assigned.

Qualifications

Required 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.

Schedule

Full Time, Days