Prime Healthcare

Clinical Documentation Specialist Trainee

Facility Saint Mary's Regional Medical Center
Business Professional
Position Type
Full Time
Job Type


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 113-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 Hospitals by Fortune/Merative and America’s Best 250 hospitals by Healthgrades, Saint Mary’s Regional Medical Center is a 380-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 a state-of-the-art Fitness Center. For more information, visit


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.


Education and Work Experience

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.


We are an Equal Opportunity/ Affirmative Action 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. EEO is the Law:


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