Clinical Documentation CDS Trainee — Medical Records

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

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.