CDS - SMRMC Medical Records

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Saint Mary’s Health Network, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

As a long-standing community partner with a 116-year history, Saint Mary’s Health Network offers Northern Nevada inpatient, outpatient, ancillary, and wellness services. Nationally recognized and accredited by the Joint Commission, as well as named one of the Top 100 Hospital s by Fortune/Merative and America’s Best 250 hospitals by Health grades, Saint Mary’s Regional Medical Center is a 352-bed acute care hospital offering a robust line of inpatient, outpatient and ancillary services including a top-rated Center for Cancer, surgical and orthopedic services, and an award-winning Cardiology program and more.

The health system, a member of Prime Healthcare, also operates a fully-integrated Medical Group, multiple urgent care clinics, freestanding imaging, lab, and primary care clinics. For more information, visit

The 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.

EDUCATION, EXPERIENCE, TRAINING

• Medical Graduate, PA or Nursing Graduate required
• Minimum of three one (1+) year’s clinical experience in an acute care setting
• 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 and 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.
• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.
• ACLS Certificate preferred.

Full Time

Days

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