Job

About the Role

We are seeking a detail-oriented and proactive Clinical Documentation Specialist to join our team. This role plays a pivotal part in improving the quality and accuracy of clinical documentation, which directly impacts patient care, coding accuracy, health fund funding and overall hospital operations. You will collaborate with medical professionals to ensure compliance with documentation standards and provide valuable insights into continuous improvement processes.

Key Responsibilities  

As a Clinical Documentation Specialist, you will be accountable for the following areas:

• Documentation Quality Assurance: Review and audit medical records to ensure clinical documentation accurately reflects the patient's condition and treatment. Provide feedback to clinicians to promote high standards of documentation that meet hospital and regulatory requirements.
• Interdisciplinary Collaboration:  Work closely with physicians, nurses, and coding staff to clarify ambiguous or incomplete documentation. Facilitate open communication and foster a culture of trust and collaboration, ensuring accurate and transparent clinical documentation.
• Education and Training:  Provide education and training to clinical staff on documentation practices, helping them understand the importance of accurate and comprehensive clinical documentation for patient safety, coding accuracy, and compliance.
• Compliance and Reporting:  Ensure all documentation meets legal, regulatory, and hospital policy requirements. Regularly report on documentation trends, areas for improvement, and compliance issues, using data-driven insights to support the hospital’s continuous improvement processes.

Qualifications & Skills:

• A background in clinical healthcare (nursing, medical records, or allied health)
• Experience in clinical documentation or health information management
• Strong communication and interpersonal skills, with the ability to educate and influence clinical staff
• Familiarity with Australian Medical Coding Standards and terminology, health fund contracts and funding models and healthcare compliance standards
• Attention to detail and analytical skills

Our Team: 

To ensure SATH is best positioned to achieve ‘Excellence in Care and Service’ it is essential our team members remain engaged and committed to providing exceptional care and service.  

Our staff are expected to align their behaviour and conduct with our Core Values of Respect, Dignity, Empathy, Courtesy, Fairness and Honesty.    

Team Member Benefits: 

• Working with dedicated, experienced, and professional team members 
• Ongoing professional development opportunities 
• Not for profit salary packaging through REMSERV up to $15,900 p.a. plus meals and entertainment packaging up to $2650 
• Free on-site carparking and uniform
• Excess waiver up to $250 per annum if admitted as a patient to St Andrew’s Toowoomba Hospital  
• Free and confidential Employee Assistance Program for all team members   

Our Commitment to Diversity: 
SATH is an Equal Opportunity Employer who provides an inclusive work environment and embraces the diverse talent of its people. We value people of all cultures, languages, capacities, sexual orientations, gender identities and/or expressions. We are committed to achieving a diverse workforce and strongly encourage applications from Aboriginal and Torres Strait Islander people.   

About us: 

St Andrew’s Toowoomba Hospital (SATH) is a progressive 155 bed private not-for-profit stand-alone facility, established in 1966.  The Hospital has a proud history of leading innovation in regional health services, including being the first regional hospital in Australia to undertake robotic assisted surgery.   

We provide acute healthcare with Specialist Consultants and Surgeons across Cardiology, Orthopaedics, Oncology, General Surgery including Breast, Colorectal and Bariatrics, Urology, Gynaecology, General Physicians, Mental Health and many more specialties and sub-specialties. We are the regional Cancer Centre with Day Oncology, Inpatient Oncology and Radiotherapy services covering an area from Northern NSW to Kingaroy, Ipswich in the East to Roma and beyond.   

As a registered not-for-profit hospital, St Andrew’s Toowoomba relies on strong community support including donations to further strengthen our vital service offering. What we make in profit is reinvested in new services, equipment, facility upgrades and refurbishments & staff training.   

About our community:  

Toowoomba is located 90 minutes’ drive west of Brisbane and boasts being Queensland’s largest inland city. Toowoomba has a great community and vibrant culture. This is coupled with a great family vibe where high quality education options are many, from Kindergarten to University; and a wide range of recreational pursuits provide something for everyone.   

As one of the fastest growing regions in Queensland, Toowoomba has a range of new and emerging infrastructure, housing and public space developments. Boasting an international airport, nationally acclaimed schools, retail development and destination dining precincts, it is quickly gaining a reputation to surpass its bigger city counterparts.  Discover more about our beautiful city at Live Toowoomba website.  

Your application must include: 

• Cover letter of no more than 2 pages focusing on the role accountabilities and our core values and how you would deliver excellent patient-centred care and service at St Andrew’s Toowoomba Hospital 
• Resume 
• Two clinical references 
• Your right to work legally in Australia e.g. an indication of your citizenship or visa status