CDS - Medical Records

OverviewJoin an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Saint Michael's Medical Center, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference. Established by the Franciscan Sisters of the Poor in 1867, Saint Michael's Medical Center is a 358-bed regional tertiary-care, teaching, and research center in the heart of Newark's business and educational district and is accredited by The Joint Commission. Combining state-of-the-art technology, the latest diagnostic and therapeutic procedures, leading-edge research, and a network of highly qualified physicians, nurses, and allied health professionals, the hospital provides top-quality health care services delivered with compassionate care.The first medical institution in New Jersey to perform open-heart surgery, and the first to develop a cardiac catheterization program, Saint Michael's Medical Center is home to the Heart and Vascular Institute, which offers a comprehensive array of innovative cardiac treatments and procedures. Learn more at .ResponsibilitiesThe Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works 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. He/She will perform other duties as assigned or required.QualificationsEDUCATION, EXPERIENCE, TRAINING1. Medical Graduate, PA or Nursing Graduate required2. Minimum of three one (1+) year’s clinical experience in an acute care setting3. Knowledge of care delivery documentation systems and related medical record documents4. Knowledge of age-specific needs and the elements of disease processes and related procedures5. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.6. Excellent written, and verbal communication skills and 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.12. ECFMG Certificate or RN license preferred.13. Prior Case Management Experience preferred.14. Working knowledge of the Medicare reimbursement system and coding structures preferred.15. Current BCLS (AHA) certificate upon hire and maintain current preferred.16. ACLS Certificate preferred.Pay TransparencySaint Michaels Medical Center 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 $32.00. 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 StatusFull TimeShiftDaysEqual Employment OpportunityCompany 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: 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: Job SummaryLocation: US-NJ-NewarkID: 2026-275500Category: Business ProfessionalPosition Type: Full TimeShift: DaysJob Type: Non-Exempt