Clinical Documentation Specialist

  • Company:
    Royal Rehab
  • Location:
  • Salary:
    negotiable / month
  • Job type:
  • Posted:
    4 days ago
  • Category:
  • Permanent full-time role available
  • Health Service Manager, level 3
  • Salary packaging available
  • NSW Health Affiliate
  • Working across multiple sites
  • Royal Rehab is a leading rehabilitation and disability support provider and registered non-profit organisation. Royal Rehab is highly regarded for specialist brain and spinal cord injury rehabilitation. Our services also incorporate supported accommodation, a private hospital, a purpose-built spinal cord injury resort and community services which provide our clients with holistic quality care.

    The Clinical Documentation Specialist is a new role for Royal Rehab and will work within the Clinical Information Department. This unit provides a range of services including clinical records management, clinical coding and case mix data generation, forms design and managing access to personal health information to facilitate patient care and follow-up, for research, quality improvement, education, and hospital management purposes.

    Your main duties will include:

  • The Clinical Documentation Specialist is responsible for the planning, design, development, implementation & delivery of ongoing audits, training, and education activities.
  • They will perform ongoing documentation reviews of medical records to clarify diagnoses and procedures where inadequate or conflicting documentation exists in a record.
  • Liaise effectively with and educate clinicians to eliminate ambiguity in documentation to improve coding specificity and optimise funding and revenue outcomes.
  • Facilitate improvements to clinical documentation to support clinical safety and patient outcomes.
  • We seek a self-motivated and friendly individual with:

  • Clinical experience in a healthcare environment and/or formal Clinical Documentation Improvement Specialist training
  • High-level communication and interpersonal skills with demonstrated ability to consult and negotiate with key stakeholders, including senior medical staff.
  • 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
  • Experience with differing medical record systems including both electronic medical records and paper based medical records
  • Excellent time management and self organisational skills.
  • Current drivers licence valid within Australia and flexibility to travel between various facilities.
  • Applications

    Applications must be submitted via our online recruitment website. To apply, please visit and complete the online application process. Applications must address the full Essential and Desirable selection criteria, as outlined in the position description.

    Further Enquiries : Sussan Nguyen, Manager of clinical information, performance & reporting

    Phone: (02) 9808 9311


    Closing Date : 25 September 2020