CDS Trainee

About This Role

This CDS Trainee role involves conducting clinically based concurrent and retrospective reviews of inpatient medical records to ensure quality of care and reimbursement compliance. The trainee will collaborate with medical staff to facilitate accurate clinical documentation of patient care.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records
• Evaluate clinical documentation for quality-of-care outcomes and reimbursement compliance
• Work closely with medical staff to facilitate appropriate clinical documentation of patient care
• Conduct documentation for inpatient admission criteria
• Perform initial and extended-stay concurrent reviews on selected admissions and document findings

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
• 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

Qualifications

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

Nice to Have

• 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
• Working knowledge of Medicare reimbursement system and coding structures

Benefits