Job

Bring your clinical expertise and communication skills to improve patient care and documentation standards in this exciting Clinical Documentation Specialist – Permanent Full-Time role!

About Central Gippsland Health 

Central Gippsland Health (CGH) is a sub-regional health service and the major provider of health and aged care services in the Wellington Shire. CGH is located in the City of Sale which is 215 km east of Melbourne. The City of Sale is an ideal access point for the magnificent Gippsland Lakes, 90 Mile Beach and the Victorian Alps.

CGH provides acute care as part of an integrated service delivery model across Wellington Shire and beyond. The service provides beds across three campuses (Sale, Maffra and Heyfield). Acute services include a full-time emergency department, critical care unit, neonatal critical care unit, three operating theatres, day procedure unit, oncology and dialysis services in addition to general medical and services and sub-acute services including rehabilitation. 

CGH is also a leading teaching hospital, affiliated with Monash University's School of Rural Health and provides placements and clinical experience for students.

About Department

The Health Information Department supports the delivery of Health Information Management to CGHS.

This is achieved through:

• Support to the clinical areas to meet high quality documentation standards.
• Support to clinical areas to ensure quality patient data in accordance with Department of Health Legislation and Policy and Instruction.
• Provision of patient information required by external agencies.
• Coding of each patient episode to reflect the services of the hospital delivered.
• Ensuring compliance with Privacy Laws and Freedom of Information requirements.

About the Role

The role of Clinical Documentation Specialist (CDS) is to actively support and facilitate an organisational-wide, advanced understanding of clinical documentation standards. Utilising proven clinical knowledge and ability to develop professional working relationships, the role 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. 

The role maintains a close collaborative working relationships with all levels of the clinical care teams, the Finance and Health Information Management (HIM) teams, and other relevant departmental or practice management staff as required.

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.

Duties

• Effectively engage with the medical staff and other health care professionals as necessary via written/verbal communication to improve the accurate and complete capture of all clinical documentation including information that supports appropriate code assignment/ DRG allocation and embeds change into practice.
• Complete reviews of patient medical records to evaluate documentation and assist to assign the principal diagnosis, additional diagnoses and procedures for accurate DRG assignment by liaising with the treating clinical team.
• Facilitate the appropriate review of clinical documentation at the point of care which reflects both care delivery and resource utilisation to support the appropriate reimbursement of services.
• Collaborate with clinical teams including doctors, nursing staff and allied health staff regarding interaction with clinicians regarding documentation and to answer clinician queries prior to discharge. 
• Provide advice for the improvement of documentation across all specialties, ward areas and related departments.

Qualifications, Skills and Experience

• A minimum of 5 years’ post graduate experience in nursing and AHPRA registration as a Registered Nurse.
• Knowledge of related medical record documents.
• Knowledge of disease processes and related procedures.
• Strong and broad clinical knowledge and understanding of pathology/pathophysiology
• High level of verbal and written skills including ability to effectively engage and educate clinicians.                                                                                                               

Benefits

• Salary packaging
• Employee Assistance Program
• Social Club

Application

• Please attach your resume and cover letter to your application
• Statement addressing Selection Criteria including qualifications, experience and Leadership and Technical Capability Requirements as outlined in the position description 

To obtain a copy of the position description, please reach out to the HR team at 03 5143 8530 or hradmin@cghs.com.au 

For questions regarding the position, contact General Manager Business Performance and Data Analytics, Aileen Onley at 03 5143 8705 or Aileen.Onley@cghs.com.au

All appointments are made subject to the candidate providing a current satisfactory National Police Certificate and obtaining a Working with Children Check.

At CGH we acknowledge the importance of creating a work environment that is welcoming, safe, equitable and inclusive. We value inclusion and diversity and encourage applicants from culturally and linguistically diverse backgrounds.

Shortlisting for this position will commence immediately. We encourage you to apply promptly as the advertisement may close early should a suitable applicant be sourced.