Clinical Documentation Improvement Specialist
Core
Improve clinical documentation standards to ensure accurate information capture for patient safety, quality of care, and hospital reimbursement.
Role type
Clinical Documentation Improvement Specialist (Nursing background)
Builds
Accurate clinical documentation and coding processes
Domain
Healthcare / Clinical Documentation / Health Information Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
AHPRA registered nursing, acute care hospital experience, clinical knowledge of pathology/physiology, change management, stakeholder engagement, data analysis, report production
Preferred skills
Post-graduate nursing course, Clinical Documentation Improvement course, knowledge of private hospital funding models, ICD-10-AM coding knowledge
Technologies
Standard office equipment
Responsibilities
Identify opportunities to improve clinical documentation, develop relationships with clinicians and nursing staff, collaborate with Health Information Services (HIS) team, monitor and analyze data for improvement opportunities, produce reports on CDI outcomes
Seniority
Mid-Senior, hands-on IC
