Clinical Documentation Specialist

We are seeking to fill the exciting position of Clinical Documentation Specialist (CDS) at Prince of Wales Private Hospital on a full or part time basis. The position would suit those looking for the next step in their Health Information Management (HIM) or nursing career or seeking to expand their skillset in the clinical documentation space.

About the Role:

The CDS has the opportunity to focus on improving the clinical documentation for Prince of Wales Private Hospital. If successful, the focus would be to provide a clinically based concurrent review of inpatient medical records to evaluate the utilisation and documentation of acute care services. The primary goals will be the facilitation of appropriate specialist documentation of care delivery to accurately reflect patient complexity, ensure fully informed patient care is provided by the treating team, and ensure the Hospital is appropriately paid for the services we provide.

As CDS you will be working alongside medical professionals and the nursing teams in this documentation review process, this is an opportunity to employ your strong relationship development skills and medical information knowledge to improve the governance and accuracy of patient records within the hospital. This is a crucial role in the hospitals operations day to day.

You will report to our Health Information Manager and work closely with the Medical Record Department, Coders, Bookings and NUMs and meet periodically with the General Manager. You will join a bi-weekly casemix meeting where you will discuss all current inpatients, their Diagnosis Related Groups (DRGs) and their surgical outcomes to date.

You will need to meet the following criteria:

• Minimum 3 years’ recent HIM or clinical experience in an acute setting.
• Strong broad based clinical knowledge and understanding of pathology/physiology relating to surgical procedures.
• Ability to deliver results within tight timeframes
• Demonstrate ability to build and maintain doctor relationships
• Excellent relationship management skills
• Strong ability to work autonomously and deliver the desired outcomes
• A basic understanding of Health Fund Contracts