Clinical Document Specialist

**Clinical Documentation Specialist**

**Permanent Full-Time or Part-time opportunities**

An exciting opportunity has become available for a Registered nurse to be trained as a Clinical Documentation Specialist, joining the established CDI Team working within Health Information Services.

**About the Role**

As the Clinical Documentation Specialist, you will be principally focussed on improving the quality of clinical documentation, held within a patient’s medical record. Once trained you will work autonomously reviewing the medical records of current inpatients to confirm that the documentation reflects the complexity of care and treatment provided. A CDS needs to communicate with medical staff about principal diagnosis options, secondary diagnosis and procedures and will ask for additions to clinical notes to satisfy coding clarity. By delivering continuous education to our clinical staff, a CDS aims to ensure quality documentation for quality, safety and to safeguard revenue.

**About You**

To succeed in this role, you will need a minimum of 5 years acute clinical experience, and preferably will have a post-graduate clinical qualification or will have worked in a leadership capacity. An extensive clinical background with an understanding of clinical terminology and diagnosis is essential. You will be a self-motivated individual who can work effectively in a team environment, but autonomously when required and have a proven ability to develop relationships with clinicians and other key stakeholders. A passion for quality improvement is desirable.

You will also have the following:

- Current registration with AHPRA as a Registered Nurse
- Extensive experience in an acute care hospital setting
- Knowledge on related medical records documentation
- Demonstrated ability to develop and maintain good physician relationships
- Excellent critical thinking skills and attention to detail
- Proficient in the use of Microsoft Office suite of programs
- Some knowledge of the Clinical Documentation Specialist role and the confidence to liaise with medical staff on patient treatment/outcomes is essential
- The successful applicant needs to have extensive experience in a number of hospital areas with ED and ICU/CCU specialties desirable

**Why Joondalup Health Campus?**

Joondalup Health Campus is the largest health care facility in Perth’s northern suburbs, providing 24-hour acute care from an integrated public and private campus.

The Hospital is operated by Ramsay Health Care, a global operator of private hospitals and primary care clinics with 72 Australian sites employing over 34,000 people. Ramsay focuses on maintaining the highest standards of quality and safety, being an employer of choice, and operating its business according to The Ramsay Way philosophy: "_People Caring for People_".

**What’s in it for you?**

**Professional Advancement**: Recognition, Rewards, Professional Development, and Employee referral programs. Free access to LinkedIn Learning, education scholarships and the Ramsay Leadership Academy to support career progression.

**Discounts**: Hospital, Allied Health & Pharmacy discounts - you’ll pay less for hospital cover and receive higher extras limits for things like General and Major Dental.

**Health and Wellbeing**: Flexible work opportunities with the ability to have a say in your roster, Flexible Leave Program, and a free Employee Assistance Program offering access to confidential counselling, coaching and support.

**Leisure/Social/Financial**: Discounts for leisure travel with selected Hotels, salary sacrifice opportunities e.g., airport lounge membership, self-education expenses, novated leasing and more.

**Requirements**:

- _Must provide a _**National Police** check conducted within the previous 12 months
- According to the role, Ramsay may require a **Working-With-Children** check and **proof of immunisation** against infectious diseases.

**To Apply