Clinical Documentation Trainee – Acute Care Records

Saint Clare's Health; Denville (NJ); On-site; USD 55,000 - 65,000; Full time

Benefits offered by this job

Paid time off

401K retirement plan

Medical

Dental

Vision coverage

Tuition reimbursement

Job summary

Saint Clare's Health seeks a CDS Trainee to perform clinically based reviews of inpatient records, ensuring documentation reflects quality of care and eligibility for reimbursement. You will work with physicians and hospital staff to optimize clinical documentation and admission criteria.

The role requires six months of acute-care experience, strong communication, and ability to work independently in a fast-paced hospital setting.

Qualifications

• 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.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate documentation reflects quality-of-care outcomes and reimbursement.
• Collaborate closely with the medical staff to facilitate appropriate clinical documentation of patient care.
• Document inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and findings.

Skills

Communication skills

Critical thinking

Interpersonal skills

Independent work

Computer literacy

Education

Medical Graduate, PA or Nursing Graduate

Job description

Saint Clare's Health seeks a CDS Trainee to perform clinically based reviews of inpatient records, ensuring documentation reflects quality of care and eligibility for reimbursement. You will work with physicians and hospital staff to optimize clinical documentation and admission criteria.

The role requires six months of acute-care experience, strong communication, and ability to work independently in a fast-paced hospital setting.