Clinical Documentation Specialist

Apply now Job no: 492784
Work type: Permanent
Location: Mater Hospital South Brisbane
Categories: All other

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: 

  • 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.

  • 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?

In return for your skills you will have the opportunity to work for an Australian leader in the field of Health and work with a team who make a real difference to the lives of our patients.


Mater provides benefits not offered in other workplaces. In addition to being part of a workplace that offers compassionate care in the spirit of the Sisters of Mercy, pioneers in the provision of healthcare to Queensland for over 100 years, you will have opportunities to increase your take-home pay with our salary packaging options. 


Closing date for applications is Friday 29 May 2020.


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


*Please note we will be reviewing and contacting applicants prior to closing date so please ensure you submit your application as soon as possible  


Advertised: E. Australia Standard Time
Applications close: E. Australia Standard Time

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