Clinical Documentation Specialist (CDS) Trainee

At North Vista Hospital, our dedicated team of professionals is 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 an accredited 177-bed state-of-the-art hospital located in North Las Vegas, Nevada. We offer comprehensive healthcare services, including mental health care, emergency care, heart care, advanced surgical procedures, diagnostic imaging, and treatment for a broad range of medical conditions. Equipped with advanced medical technology and staffed by 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 the Patient Safety Excellence Award, Bariatric Surgery Excellence Award, and Heart Failure recognition.

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 provided.
• Collaborate closely with 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.
• Perform additional duties as assigned.

Requirements

• 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.
• Understanding 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.

Schedule

• Full Time
• Day Shift