Clinical Documentation Specialist

3 weeks ago


South Brisbane, Australia Mater Group Full time

**Job no**: 497631

**Work type**: Permanent

**Location**: South Brisbane

**Categories**: All other

Mater is Queensland’s largest and most innovative not-for-profit healthcare service, providing care for almost 700,000 patients a year across a network of 11 hospitals.

We are a leader in healthcare, education and research — and that’s because we employ exceptional people.

**About the role**

Mater Revenue Assurance Unit currently has a rewarding opportunity to join the team as a **Clinical Documentation Specialist**. This position is offered on a permanent, full-time basis based at our South Brisbane campus. Part time to 0.8 FTE will be considered.

In this pivotal role you will advise and support clinicians including Mater doctors, VMOs, nursing and allied health staff in the requirements of accurate and complete clinical documentation as required by the ICD-10-AM and AR-DRG classifications, in order to capture all contributing factors to patient care, acuity and complexity in the coded data as guided by the Australian Coding Standards.

This position will improve the quality of documentation to support best clinical practice and the Mater’s ability to be appropriately remunerated for patient activity. In turn, this will establish a sustainable approach to the accurate and complete capture of required clinical documentation for clinical coding purposes and associated inpatient clinical documentation review processes.

**Salary range: Commensurate with experience**

**What you’ll be doing**

Key accountabilities will include:

- Identify opportunities and priorities for inpatient clinical documentation improvement across Mater and initiate clinical documentation improvement initiatives where these are not in in place or not effective/sustained.
- Undertake inpatient clinical documentation review.
- Coach, mentor and support Mater clinical staff responsible for/assisting with inpatient clinical documentation review.
- Monitor and measure the performance and outcomes of Mater’s inpatient clinical documentation improvement initiatives and identify and recommend where and how further improvements can be achieved
- Identify and implement strategies to overcome barriers to effective clinical documentation as it relates to the recording of diagnostic and treatment information required for clinical coding
- Work collaboratively with clinical staff accountable and responsible for clinical documentation and inpatient clinical documentation review
- Partner with the Clinical Coding Service to identify and target areas for clinician education and clinical documentation improvement including the review of clinical coding queries and coding audit findings
- Contribute to the development of and champion the utilisation of clinical documentation guides and other clinical documentation resources for clinical staff
- Connect with the Australian and international clinical documentation improvement community and resources including the Association of Clinical Documentation Improvement Specialists

**About you**

To be successful in this role you will possess a broad-based clinical knowledge and understanding of pathology/physiology of disease processes and minimum of 5 years recent experience working in a hospital clinical care environment and hold a Bachelor of Nursing.

You will also possess:

- Good understanding of clinical documentation in a hospital environment and experience in auditing and reviewing clinical documentation for variance, completeness, and improvement
- Proven ability and experience in implementing change and improvement processes in a clinical environment with successful outcomes

**Why join us?**

Joining a 10,000+ strong workforce, you will have the opportunity to work for an Australian leader in the field of Health, Education, Research and Foundation and work with a team who make a real difference to the lives of our patients, consumers, and community. You will be a part of a workplace that offers compassionate care in the spirit of the Sisters of Mercy.
- Increase take-home pay via Salary Packaging
- Access to package meal and entertainment expenses
- Access to leading education through Mater Education
- Flexible working arrangements & work from home options for suitable roles
- Access to our Employee Assistance Program and on-site pastoral care team
- Discounts at local and national businesses on dining, retail, travel, and accommodation
- Access to on-site, discounted parking
- Discounted food and beverages at various campus cafés and coffee venues

For further information, please contact **Regan Dent, Revenue Optimisation Manager on 07 3163 6022**

It is a mandatory requirement of employment at Mater that you are and remain fully vaccinated against Covid-19.

**Advertised**: 01 Feb 2023 E. Australia Standard Time
**Applications close**: 12 Feb 2023 E. Australia Standard Time


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