Job Description

Overview

We are seeking a Clinical Documentation Specialist Trainee , sometimes referred to as a Medical Records Documentation Analyst – Trainee , or CDS Trainee in our medical records department. Our CDS Trainee in the medical records department of the hospital is a professional learning environment .  The CDS Trainee will ensure that patient medical records accurately and completely reflect the clinical care provided. CDS Trainee’s work supports accurate coding, billing, compliance, and patient care data.

Shift’s Available:  Days 

Employment Type: Full-Time

Hours: 8-hour – 8:00am to 5:00pm (Some w eekends will be required )

Location: Harlingen Medical Center – Harlingen, TX

Here are some of the benefits of working at Prime Healthcare:

• Health, dental, and vision insurance options

• Paid vacation, sick time and holidays

• Bereavement leave , FMLA and other leave options

• Employer 401K options

• Tuition reimbursement options 

• Life, disability, and other insurance options

• Many other amazing benefits

Full benefits at Prime Healthcare:

*** If you are a Medical Graduate, Physician Assistant (PA ) or Nursing Graduate you are encouraged to apply!**

Responsibilities

Essential Duties and Responsibilities (includes, but not limited to):

• Assist in reviewing inpatient and outpatient medical records to ensure accurate documentation of diagnoses, procedures, and treatments

• Learn to identify missing, unclear, or inconsistent documentation that could affect coding accuracy or reflect incomplete clinical data

• Support the development of clinical queries under supervision to clarify provider documentation for coding and compliance

• Collaborate with CDS staff, coders, physicians, and nurses to strengthen documentation practices across the care team

• Receive training in ICD-10 coding, DRG assignment, healthcare regulations, and how documentation impacts reimbursement compliance and quality metrics

Qualifications

Before we go any further, we do have some deal-breakers. You must have: 

EDUCATION, EXPERIENCE, TRAINING

1. Medical Graduate, PA or Nursing Graduate required. 

2. Minimum of six (6) months of clinical experience in an acute care setting in any capacity.

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. 

12. Working knowledge of Medicare reimbursement system and coding structures preferred.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

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: 

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