Clinical Documentation Specialist

4 weeks ago


Sydney, Australia NSW Health Full time

An exciting opportunity exists for two temporary full time Clinical Documentation Specialists (CDS) to join the Northern Sydney Local Health District Coding Team. The CDS position is based at Hornsby Hospital and forms part of the Clinical Documentation Improvement Program to be implemented in Hornsby Hospital to increase awareness of the importance of clinical documentation and impact to clinical coding and funding outcomes.

**Employment Type**: Temporary Full Time until 1 July 2024

**Position Classification**: Health Manager Level 2

**Remuneration**: $1,967.09 - $2,333.12 per week

**Hours Per Week**: 38

**Requisition ID**: REQ405786

**Where you'll be working**
Hornsby Ku Ring-Gai Hospital

**What you'll be doing**

The purpose of the position is to facilitate improvements to clinical documentation and to promote the importance of quality documentation for accurate coding and appropriate reimbursement allocation in an Activity Based Funding environment to reflect level of service provided to patients.
The Clinical Documentation Specialist will perform ongoing documentation review of inpatient records to clarify diagnoses and procedures where inadequate or conflicting documentation exists in a record.
Identification and correction of documentation issues impacting accurate DRG assignment will ensure documentation reflects the level of service provided to patients is complete and accurate.
This will be achieved by interaction and liaison with clinical, nursing and allied health staff at all levels within the NSLHD to improve clinical documentation.

**_People of Aboriginal and/or Torres Strait Islander background encouraged to apply._**
- Consistently demonstrates behaviours that reinforce the CORE Values of our organisation; Collaboration, Openness, Respect and Empowerment. Demonstrates these behaviours with all stakeholders; colleagues, direct reports, as well as our patients and consumers, and those that care for them.
- Clinical experience in an acute care environment and/or formal qualifications of Health Information Manager with demonstrated knowledge and extensive experience across a broad range of specialties
- Demonstrated ability to implement change initiatives in a large and complex health service environment with ability to develop and deliver education to clinical staff on continuous documentation quality improvement
- Highly developed interpersonal skills with experience engaging and influencing key stakeholders and multidisciplinary groups to influence others to move toward a common vision or goal
- Extensive knowledge in clinical documentation standards and understanding of clinical coding documentation requirements
- Highly professional oral and written communication skills, particularly in development and delivery of reports, training materials, education sessions and presentations to promote the importance of quality documentation for accurate coding and appropriate reimbursement allocation
- Demonstrated Experience with clinical information systems such as eMR and 3M Codefinder with understanding of their relevance to clinical coding and Activity Based Funding
- Strong analytical, organisational and time management skills to enable the completion of high volume workload and the ability to work autonomously and within a team. Must also be able to work outside normal working hours when required to meet with clinicians

Need more information?

1) Click here for the Position Description
- All NSW Health workers are required to have two doses of a COVID-19 vaccine, as defined by NSW Health. Employees working in a clinical area or are required to attend clinical areas are considered category A. Category A positions are required to provide evidence of having received three doses of COVID-19 vaccine in accordance with the Australian Technical Advisory Group on Immunisation (TGA) and meet the requirements of the _Occupational Assessment Screening and Vaccination Against Specified Infectious Diseases Policy Directive_._
- Acceptable proof of vaccination is the Australian Immunisation Register (AIR) Immunisation History Statement or AIR COVID-19 Digital Certificate._

**Applications Close: 10 July 2023



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