Clinical Quality Documentation Specialist I

Northwestern Memorial Healthcare • Chicago, IL

1d • $37 - $56

About The Position

The Clinical Quality Documentation Specialist I supports Northwestern Medicine’s mission, vision, and values and complies with its ethical, regulatory, accreditation, and organizational requirements. The role improves the completeness and accuracy of quality data and outcomes through extensive collaboration with physicians, nursing staff, interdisciplinary quality committees, multidisciplinary teams, and clinical coders. It applies clinical expertise, knowledge of quality initiatives and nursing standards, current research, best practices, and interdisciplinary collaboration to improve clinical documentation and redesign processes.

The specialist serves as a change agent, implementing priorities set by Clinical Documentation Leadership and senior clinical and quality leaders or quality and safety committees. The role participates in performance improvement initiatives and monitors control plans and data trends in collaboration with clinical quality committees and physician practices. Through in-person interaction, the specialist promotes documentation that accurately represents patient characteristics and supports accurate process and outcome measures.

The position rounds with physicians and advanced practice providers, reviews medical records, identifies documentation and quality improvement opportunities, analyzes quality and patient safety data, and partners with operational and medical leaders on communication, education, and process improvement. It also contributes to committee work, professional development, and ongoing performance improvement activities.

Requirements

• Registered Nurse in the State of Illinois.
• Bachelor’s or Master’s degree in nursing.
• At least 2 years of bedside nursing experience and participation in clinical quality, patient safety, or related initiatives, with evidence of effective change management skills.
• Strong interpersonal, communication, conflict management, diplomacy, and negotiation skills.
• Proven leadership ability to affect positive clinical quality outcomes.
• Analytical skills to independently collect, analyze, and interpret clinical data.
• Basic computer skills and willingness to learn computer applications relevant to the position.

Nice To Haves

• Master’s degree.
• Five years’ experience in medical/surgical, critical care, intensive care, or emergency care.

Responsibilities

• Maintain relationships with business-unit and system physician and administrative leaders to advance quality metrics through frontline documentation efforts.
• Round daily with physicians and advanced practice providers in assigned service lines or business units to promote appropriate and accurate medical record documentation and ensure care level and acuity are accurately reflected in quality outcomes.
• Partner with operational and medical leadership to develop and implement communication and education strategies that engage physicians and improve processes and outcomes.
• Conduct daily medical record reviews and collect data to identify documentation issues, quality issues, and opportunities to improve patient care and services.
• Apply an understanding of local and national quality and ranking methodologies, including U.S. News & World Report, Vizient, Leapfrog, CMS Star Rating, and payer contracts, and assist Clinical Documentation Managers in executing and maintaining strategies for change.
• Use the NM network to initiate conversations, identify root causes and resolutions, and align resources.
• Analyze quality and patient safety data, including hospital-acquired conditions, patient safety indicators, case mix index, and expected mortality, to identify patterns in patient care and services.
• Collaborate with the Clinical Quality Team to model, teach, and improve a culture of safety and shared improvement.
• Present updates to operational and medical leaders, attending and resident physicians, and interdisciplinary quality committees.
• Collaborate with colleagues and the Clinical Coding Team to support accurate reporting of patient diagnoses, comorbid conditions, and treatment rendered.
• Maintain knowledge of evidence and literature in relevant clinical areas, clinical quality improvement, patient safety, human factors, failure modes, root cause analysis, and related performance and safety resources.
• Apply professional nursing standards, best practices, and interdisciplinary collaboration to problem analysis, resolution, and process redesign.
• Participate in at least one NM Clinical Documentation committee as approved by the Manager, Clinical Documentation.
• Participate in departmental and hospital committees and task forces as assigned.
• Participate in concurrent performance improvement and ongoing review activities.
• Perform other job-related duties and special projects as requested.
• Comply with patient confidentiality policies, including HIPAA requirements and Personal Rules of Conduct.

Benefits

• Northwestern Medicine describes a wide range of benefits supporting employees’ physical, emotional, and financial well-being and protection from unexpected life events.
• Tuition reimbursement.
• Loan forgiveness.
• 401(k) matching.
• Lifecycle benefits.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level