Clinical Documentation Specialist Trainee (CDS) - Medical Records
Philadelphia, PA 
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Posted 20 days ago
Job Description
Clinical Documentation Specialist Trainee (CDS) - Medical Records
Facility Roxborough Memorial Hospital
Location US-PA-Philadelphia ID 2024-158798 Category Business Professional Position Type Full Time Shift Days Job Type Non-Exempt
Overview

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Roxborough Memorial Hospital, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

Roxborough Memorial Hospital is a 131-bed community hospital. The hospital has been serving the medical and health care needs of the Roxborough, Manayunk, East Falls and northwest section of Philadelphia communities for more than a century, having first opened its doors in 1890. Roxborough Memorial Hospitals School of Nursing has been educating nurses since 1898. The hospital is accredited by the Joint Commission on the Accreditation of Healthcare Organizations, the nation's oldest and largest hospital accreditation agency.

We are an Equal Opportunity Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation, or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

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 work 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 provided.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1. Medical Graduate, PA or Nursing Graduate.
2. Minimum of 3 years clinical experience in an acute care setting.
3. Knowledge of care delivery documentation systems and related medical record documents.
4. Knowledge of age-specific needs and the elements of disease processes and related procedures.
5. Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
6. Excellent written and verbal communication skills. Excellent critical thinking skills.
7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.
8. Working knowledge of inpatient admission criteria.
9. Ability to work independently in a time-oriented environment.
10. Computer literacy and familiarity with the operation of basic office equipment.
11. Assertive personality traits to facilitate ongoing physician communication.

Preferred qualifications:

1. Working knowledge of Medicare reimbursement system and coding structures preferred.

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We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender,gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.
EEO is the Law: http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf

 

Job Summary
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Experience
2 to 3 years
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