Clinical Documentation Specialist Trainee (CDS) - Medical Records
Updated: June 29
Philadelphia
Roxborough Memorial Hospital
0
0mi
Job Abstract
Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Roxborough Memorial Hospital, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference. Roxborough Memorial Hospital is a 131-bed community hospital. The hospital has been serving the medical and health care needs of the Roxborough, Manayunk, East Falls and northwest section of Philadelphi... more details
Clinical Documentation Specialist Trainee (CDS) - Medical Records
FacilityRoxborough Memorial Hospital
Location
US-PA-Philadelphia
ID
2024-166401
Category
Business Professional
Position Type
Full Time
Shift
Days
Job Type
Non-Exempt
Overview
Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Roxborough Memorial Hospital, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.
Roxborough Memorial Hospital is a 131-bed community hospital. The hospital has been serving the medical and health care needs of the Roxborough, Manayunk, East Falls and northwest section of Philadelphia communities for more than a century, having first opened its doors in 1890. Roxborough Memorial Hospitals School of Nursing has been educating nurses since 1898. The hospital is accredited by the Joint Commission on the Accreditation of Healthcare Organizations, the nation's oldest and largest hospital accreditation agency.
We are an Equal Opportunity Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation, or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf
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 work 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 provided.
Qualifications
EDUCATION, EXPERIENCE, TRAINING
Required qualifications:
1. Medical Graduate, PA or Nursing Graduate. 2. Minimum of 3 years clinical experience in an acute care setting. 3. Knowledge of care delivery documentation systems and related medical record documents. 4. Knowledge of age-specific needs and the elements of disease processes and related procedures. 5. Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes. 6. Excellent written and verbal communication skills. Excellent critical thinking skills. 7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff. 8. Working knowledge of inpatient admission criteria. 9. Ability to work independently in a time-oriented environment. 10. Computer literacy and familiarity with the operation of basic office equipment. 11. Assertive personality traits to facilitate ongoing physician communication.
Preferred qualifications:
1. Working knowledge of Medicare reimbursement system and coding structures preferred.
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