CDS - SMRMC Medical Records

Prime Healthcare; Reno, Northern (NV, KY); Hybrid; USD 80,000 - 110,000; Full time

Job summary

Saint Mary’s Health Network in Reno, NV is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation reflects quality of care and supports appropriate reimbursement. You will collaborate with physicians and staff to optimize documentation and admissions criteria, while maintaining current clinical standards.

Ideal candidates hold a medical graduate, PA, or nursing degree, with acute care experience and strong

Qualifications

• Medical Graduate, PA or Nursing Graduate required.
• Minimum of three one (1+) year’s clinical experience in an acute care setting.
• 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 and 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.
• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.
• ACLS Certificate preferred.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate whether the clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services.
• Work closely with the medical staff to facilitate appropriate clinical documentation of patient care.
• Perform documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.
• Perform other duties as assigned or required.

Skills

Clinical documentation

Communication skills

Critical thinking

Interpersonal skills

Independence

Education

Medical Graduate, PA or Nursing Graduate

ECFMG/RN license preferred

Job description

Overview

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Saint Mary’s Health Network, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

As a long-standing community partner with a 116-year history, Saint Mary’s Health Network offers Northern Nevada inpatient, outpatient, ancillary, and wellness services. Nationally recognized and accredited by the Joint Commission, as well as named one of the Top 100 Hospitals by Fortune/Merative and America’s Best 250 hospitals by Healthgrades, Saint Mary’s Regional Medical Center is a 352-bed acute care hospital offering a robust line of inpatient, outpatient and ancillary services including a top-rated Center for Cancer, surgical and orthopedic services, and an award-winning Cardiology program and more. The health system, a member of Prime Healthcare, also operates a fully-integrated Medical Group, multiple urgent care clinics, freestanding imaging, lab, and primary care clinics. For more information, visit www.SaintMarysReno.com.

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works 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. He/She will perform other duties as assigned or required.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

• Medical Graduate, PA or Nursing Graduate required
• Minimum of three one (1+) year’s clinical experience in an acute care setting
• 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 and 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.
• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.
• ACLS Certificate preferred.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf