Clinical Documentation Improvement Specialist

Epworth HealthCare is Victoria’s largest not-for-profit private hospital group, renowned for excellence in diagnosis, treatment, care and rehabilitation. Epworth is an innovator in Australia’s health system, embracing the latest in evidence-based medicine to pioneer treatments and services for our patients. 

At Epworth, we are united in our commitment to fostering a diverse and inclusive workplace—one that is culturally safe and respectful of the enduring cultural and spiritual connections of our people.

We value all differences, ensure equitable practices, and empower individuals to lead and learn inclusively in their everyday interactions. Our goal is to create an environment where everyone feels a genuine sense of belonging.

Our values and purpose define Epworth's approach and delivery. We pride ourselves on communicating and delivering them in a real and meaningful way. Every Patient Matters.

Great opportunity to actively support and facilitate an organisational-wide, advanced understanding of clinical documentation standards.

Utilising your proven clinical knowledge and ability to develop professional working relationships, you 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. Your positive personality will be able to leverage relationships with Clinical & Non-Clinical teams, Health Fund & Health Information Services, and other key stakeholders to ensure the long-term success of this program.

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. The role maintains a close collaborative working relationship with all levels of the Clinical Care team, Health Fund team, Health Information Services and other relevant departmental/ practice management staff as required.

You will make an impact by:

• Using your relevant experience to identify opportunities to improve clinical documentation.
• Developing strong relationships with clinicians and nursing staff that will enable you to influence and drive cultural change.
• Working collaboratively with the HIS team. Act as a conduit between clinicians and HIS to help drive efficiencies and improvements in the clinical coding process.
• Monitoring and analysing data to seek areas of opportunity.
• Producing reports on outcomes as a result of the CDI activities.

To be successful in this role..

You are self-driven, ambitious and like to take initiative. You have experience working in an acute care hospital setting and enjoy collaborating with stakeholders to help drive improvement in clinical documentation. The ability to engage with clinicians and other key stakeholders is the critical success factor in this role.

You will have:

• Current nursing registration with AHPRA.
• Experience working in an acute care hospital setting.
• Demonstrated ability to lead and implement change and influence clinical staff across all levels.
• Ability to demonstrate and facilitate excellent working relationships with clinicians.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Computer literacy and familiarity with the operation of standard office equipment.
• Highly developed written, verbal and communication skills with strong interpersonal skills to liaise and consult with a range of staffing groups.
• Knowledge of private hospital funding models and an understanding of ICD -10-AM coding and clinical documentation standards is desirable.

Position Description          Inherent Requirements

You will bring :

• AHPRA Registered Nurse, with a minimum of 5+ years post graduate experience or completion of Health Information Management degree / Clinical Coding course.
• Completion of Post-Graduate nursing course (advantageous).
• Completion of Clinical Documentation Improvement course (advantageous).
• Demonstrated experience in role knowledge requirements for an appropriate period.
• Recent senior clinical nursing experience in an acute care setting, or;
• Casemix management or discharge planning experience in acute casemix settings.
• Recent private health sector experience, knowledge of current funding payment models and contractual arrangements in a medium to large organisation
• Working knowledge of/or ability to acquire knowledge of clinical coding documentation requirements

Why Join Epworth?

It’s the sense of belonging and being part of an organisation and a team that works to make sure that every patient matters. In addition to this, you will have access to:

• Salary package up to $15,900 pre-tax annually, leading to greater take home pay
• The largest educational scholarship program of its kind in Australia
• Ability to purchase up to four additional weeks of leave
• Reduced cost of health services for you and your family at Epworth
• Relocation assistance is available for approved candidates

We welcome applicants from all backgrounds. This includes First Nations peoples, people with disability, mature-age and young job seekers, members of the LGBTIQA+ community, and individuals from all cultural backgrounds. We are committed to providing an equitable, inclusive, and barrier-free recruitment experience for everyone.

If you need support during the application process or would like to discuss reasonable adjustments, we encourage you to let us know what you need to participate fully and confidently. We understand that sharing your needs can feel daunting, so please know that any information you provide will be treated with the utmost confidentiality and respect.

Ready to Make a Difference?

To apply, click the I'm Interested button to attach your CV and cover letter.

For more information about the role, refer to the attached position description or contact [email protected] or call (03) 9426 0606.

It is a condition of employment with Epworth HealthCare, subject to reasonable exemptions, that you have had an annual Influenza vaccination, where this is required under Epworth policy.

As a child safe organisation, all successful applicants are required to satisfactorily clear a National Police Check (conducted by Epworth) and may be required to hold a valid employee Working with Children Check (provided by you).

At Epworth, we believe inclusion and diversity are essential to our culture and values. We focus on fairness and opportunity for all – across race, ability, ethnicity, gender, age, sexuality, cultures and beliefs – that reflect the communities we work in. At Epworth, we care.