CDS Trainee - SCDNNJ Medical Records Fac#01

Prime Healthcare; Lake Arrowhead (NJ); On-site; USD 60,000 - 80,000; Full time

Job summary

Saint Clare's Health is seeking a CDS Trainee to perform clinically based concurrent and retrospective reviews of inpatient medical records, ensuring documentation reflects quality of care and reimbursement compliance for acute services.

You will collaborate with medical staff to document patient care, assist with inpatient admission criteria, and conduct ongoing reviews across selected cases, contributing to the hospital's commitment to safe, high‑quality care.

Qualifications

• Medical graduate, PA or nursing graduate required.
• Minimum six months of clinical experience in acute care.
• Knowledge of care delivery documentation systems and related medical record documents.
• Strong communication, critical thinking and interpersonal skills.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate quality-of-care outcomes and reimbursement for acute services.
• Collaborate with medical staff to facilitate appropriate clinical documentation of patient care.
• Document inpatient admission criteria and ongoing reviews for selected admissions, including initial and extended-stay reviews.
• Perform other duties as assigned.

Skills

Communication skills

Critical thinking

Interpersonal skills

Independent work

Documentation literacy

Education

Medical Graduate, PA or Nursing Graduate

Tools

EMR systems

Job description

Overview

At Saint Clare's Health, our dedicated team of professionals is committed to our core values of quality, compassion, and community. As a member of Prime Healthcare, Saint Clare's Health is actively seeking new members to join its award-winning team!

Saint Clare's Health includesCMS 5-Star Ratedhospitals and is an award-winning provider of safe, high quality, compassionate care, serving the communities of Morris, Warren and Sussex counties. Its network of hospitals and healthcare facilities include Denville Hospital, Dover Hospital, Behavioral Health Centers in Boonton, Denville, and Parsippany, and an Imaging Center in Parsippany, among other satellite locations. The hospitals have received multiple quality awards including Leapfrog “A” ratings for patient safety; Healthgrades recognition for orthopedic surgery, treatment of stroke, heart care, various surgical procedures, and more. For information, visit www.saintclares.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.

Pay Transparency

Saint Clare's Health offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $XX.00 to $XX.00. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

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