Clinical Documentation Specialist (CDS) Trainee

The hospital has achieved numerous quality award distinctions including Patient Safety Excellence Award, Bariatric Surgery Excellence Award, Heart Failure recognition and more. For more information, please visit www.northvistahospital.com.

Responsibilities

CDS Trainee is responsible for conducting 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. CDS Trainee will collaborate closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings Additional duties as assigned.

Qualifications

Education, experience, training

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.