Clinical Quality Documentation Specialist I

Northwestern Memorial Healthcare • Chicago, IL

23h

About The Position

The Clinical Quality Documentation Specialist I advances the completeness and accuracy of quality data and outcomes through extensive collaboration with physicians, nursing staff, interdisciplinary quality committees, multidisciplinary teams, and clinical coders. Applying clinical expertise, knowledge of the national quality agenda, professional nursing standards, current research, and best practices, the specialist supports analysis and redesign of clinical documentation processes. The role acts as a change agent to implement priorities established by Clinical Documentation Leadership, senior clinical and quality leaders, and quality and safety committees.

The specialist participates in performance improvement initiatives and monitors control plans and data trends in collaboration with clinical quality programs, committees, and physician practices. A central focus is promoting accurate documentation through in-person interaction so that medical records represent patient characteristics and quality measures accurately. The role also supports a culture of safety and continuous improvement, and complies with organizational policies, professional standards, and applicable regulatory and accreditation requirements.

Requirements

• Registered Nurse in the State of Illinois.
• Bachelor’s or master’s degree in nursing.
• At least 2 years of bedside nursing care 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.
• Demonstrated leadership 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.
• Help ensure the level of services and acuity of care are accurately reflected in quality outcomes.
• Partner with operational and medical leadership to identify, develop, and implement communication and education that engage physicians and improve processes and outcomes.
• Perform daily medical-record reviews in assigned service lines.
• Collect data to identify documentation and quality issues and opportunities to improve patient care and services.
• Support strategies related to local and national quality and ranking methodologies, including U.S. News & World Report, Vizient, Leapfrog, CMS Star Rating, and payer contracts.
• Use the Northwestern Medicine 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.
• Collaborate with the Clinical Quality Team to model, teach, and improve the culture of safety and shared improvement.
• Present updates to operational and medical leadership, attending and resident physicians, and interdisciplinary quality committees.
• Communicate and collaborate effectively with colleagues and the Clinical Coding Team.
• Promote accurate reporting of patient diagnoses, comorbid conditions, and treatment rendered.
• Review clinical evidence and literature in relevant clinical areas, disciplines, and improvement science, including quality improvement, patient safety, human factors, failure modes, and root cause analysis.
• 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, as well as concurrent performance improvement and ongoing review activities.
• Perform other job-related duties and special projects as requested.
• Comply with patient-confidentiality policies, HIPAA requirements, and Personal Rules of Conduct.

Benefits

• Competitive benefits, including tuition reimbursement, loan forgiveness, and 401(k) matching.
• A wide range of benefits intended to support employees’ physical, emotional, and financial well-being and provide protection for unexpected life events.

What This Job Offers

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