Job

An exciting opportunity exists for two Clinical Documentation Specialist (CDS) to join the Northern Sydney Local Health District (NSLHD) Coding Team. The CDS will provide high level expert advice to drive improvements in quality of clinical documentation including education of clinicians to improve coding specificity.

Who we are: We are a health service that touches thousands of lives across the Northern Sydney Local Health District, together as a team of like-minded people. We are passionate, driven and have the skills and knowledge to care for our patients whilst creating the best services possible. Our teams have meaningful, interesting and rewarding work everyday. We challenge and nurture each other, sharing our knowledge and experience so that we can deliver better care for everyone There’s a real sense of belonging here because we value and respect our patients, employees, and teams’ voices. You’ll feel a real privilege being a trusted caregiver in our patients, their families, their carers, and our communities’ lives.

NSLHD is proud of our diverse and inclusive workplaces, a place where health care professionals can thrive and feel they belong. We are committed to ensure that all our people feel respected and participate safely within a work environment without aggression, sexual harassment, discrimination and racism.  

Where you'll be working
Royal North Shore Hospital (with possible remote work option)

What you'll be doing

The purpose of the position is to facilitate improvements to clinical documentation and to promote the importance of quality documentation for accurate coding and appropriate reimbursement allocation in an Activity Based Funding environment to reflect level of service provided to patients.       
The Clinical Documentation Specialist will perform ongoing documentation review of inpatient records to clarify diagnoses and procedures where inadequate or conflicting documentation exists in a record.  
 
Identification and correction of documentation issues impacting accurate DRG assignment will ensure documentation reflects the level of service provided to patients is complete and accurate.
 
This will be achieved by interaction and liaison with clinical, nursing and allied health staff at all levels within the NSLHD to improve clinical documentation.

People of Aboriginal and/or Torres Strait Islander background encouraged to apply.

Candidates will need to meet the following criteria:

1. Clinical experience in an acute care environment and/or formal qualifications of Health Information Manager with demonstrated knowledge and extensive experience across a broad range of specialties.
2. Demonstrated ability to implement change initiatives in a large and complex health service environment with ability to develop and deliver education to clinical staff on continuous documentation quality improvement.
3. Demonstrated experience with clinical information systems such as eMR and 3M Codefinder with understanding of their relevance to clinical coding and Activity Based Funding.