CDS Trainee: Acute Care Documentation Specialist

Prime Healthcare; Lynwood (CA); On-site; USD 36,000 - 40,000; Full time

Job summary

Prime Healthcare in Ontario, California is seeking a CDS Trainee to conduct concurrent and retrospective reviews of inpatient medical records to ensure documentation reflects quality of care and proper reimbursement. It is a full-time Days role with competitive compensation.

You will work with medical staff to facilitate accurate clinical documentation, review admission criteria, and document findings for selected admissions. Other duties as assigned in a corporate CDS program.

Qualifications

• Medical graduate, PA or nursing graduate.
• Minimum six months of acute care clinical experience.
• Knowledge of care delivery documentation systems and medical record documents.
• Understanding of age-specific needs and disease processes.
• Strong clinical knowledge of pathology/physiology.
• Excellent written and verbal communication.
• Excellent critical thinking.
• Excellent interpersonal skills to build collaborations with physicians, staff and management.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and basic office equipment.
• Assertive to facilitate physician communication.
• Preferred: Medicare reimbursement knowledge and coding structures.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient records.
• Evaluate that documentation reflects quality of care and reimbursement compliance.
• Collaborate with medical staff to facilitate accurate clinical documentation.
• Document inpatient admission criteria and initial/extended-stay reviews.
• Document findings for selected admissions; perform other duties as assigned.

Skills

Clinical documentation

Communication skills

Critical thinking

Interpersonal skills

Independence

Computer literacy

Education

Medical Graduate

PA Graduate

Nursing Graduate

Job description

Prime Healthcare in Ontario, California is seeking a CDS Trainee to conduct concurrent and retrospective reviews of inpatient medical records to ensure documentation reflects quality of care and proper reimbursement. It is a full-time Days role with competitive compensation.

You will work with medical staff to facilitate accurate clinical documentation, review admission criteria, and document findings for selected admissions. Other duties as assigned in a corporate CDS program.