Job Description

Great opportunity to actively support and facilitate an organisational-wide, advanced understanding of clinical documentation standards.

Utilising your proven clinical knowledge and ability to develop professional working relationships, you will focus upon all aspects of documentation that improve information capture for patient safety, quality of care and inter- clinician communication, along with ensuring accurate hospital reimbursement. Your positive personality will be able to leverage relationships with Clinical & Non-Clinical teams, Health Fund & Health Information Services, and other key stakeholders to ensure the long-term success of this program.

The goal of this program is to ensure clinical documentation is complete, specific and accurate to ensure the complexity of the episode of care is appropriately reflected. The role maintains a close collaborative working relationship with all levels of the Clinical Care team, Health Fund team, Health Information Services and other relevant departmental/ practice management staff as required.

You will make an impact by:

- Using your relevant experience to identify opportunities to improve clinical documentation.
- Developing strong relationships with clinicians and nursing staff that will enable you to influence and drive cultural change.
- Working collaboratively with the HIS team.



Act as a conduit between clinicians and HIS to help drive efficiencies and improvements in the clinical coding process.
- Monitoring and analysing data to seek areas of opportunity.
- Producing reports on outcomes as a result of the CDI activities.

To be successful in this role..

You are self-driven, ambitious and like to take initiative. You have experience working in an acute care hospital setting and enjoy collaborating with stakeholders to help drive improvement in clinical documentation. The ability to engage with clinicians and other key stakeholders is the critical success factor in this role.

You will have:

- Current nursing registration with AHPRA.
- Experience working in an acute care hospital setting.
- Demonstrated ability to lead and implement change and influence clinical staff across all levels.
- Ability to demonstrate and facilitate excellent working relationships with clinicians.
- Solid broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
- Computer literacy and familiarity with the operation of standard office equipment.
- Highly developed written, verbal and communication skills with strong interpersonal skills to liaise and consult with a range of staffing groups.
- Knowledge of private hospital funding models and an understanding of ICD -10-AM coding and clinical documentation standards is desirable.

Position Description Inherent Requirements

📌 Clinical Documentation Improvement Specialist (Richmond)
🏢 Epworth
📍 Richmond