Lead Clinical Quality Documentation Specialist
About The Position
The Lead Clinical Quality Documentation Specialist is a Registered Professional Nurse and expert in clinical documentation integrity, responsible for leading documentation initiatives that support Northwestern Medicine and its business units’ strategic goals. Under the direction of Clinical Documentation program leadership, this role drives cross-regional change and program enhancements, anticipates and resolves issues, recommends best practices, aligns resources, and implements solutions. The specialist leads stakeholder conversations and coaches documentation team members through challenging projects and issues, systematically improving documentation and coding practices to advance financial and quality outcomes. The role applies advanced knowledge of national quality priorities and clinical documentation integrity best practices to analyze problems and redesign processes. It collaborates with clinical documentation and medical leadership, system and business-unit stakeholders, and teams across Northwestern Medicine. Scope includes functions supporting documentation in the patient medical record and practitioners, clinicians, trainees, students, employees, volunteers, and others involved in delivering or supporting patient care. Travel may be required to support business needs.
Requirements
- Registered Nurse in the State of Illinois.
- Bachelor’s or master’s degree in nursing.
- At least 3 years of Clinical Documentation Integrity experience.
- 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.
- Current certification in clinical documentation, such as certification from the Association of Clinical Documentation Integrity Specialists (ACDIS).
- Demonstrated advanced clinical expertise.
- 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.
- Strong computer skills and familiarity with computer applications relevant to the position.
Nice To Haves
- Master’s degree in a relevant field.
- Microsoft Office suite skills relevant to the role.
Responsibilities
- Serve as a clinical documentation resource and role model, applying advanced clinical documentation integrity expertise.
- Collaborate with clinical documentation, medical, coding, quality, nutrition, and clinical leaders to align and advance documentation work across Northwestern Medicine.
- Apply professional practice knowledge, documentation standards, best practices, and interdisciplinary collaboration to analyze problems and redesign processes.
- Use knowledge of local and national quality and ranking methodologies, including U.S. News & World Report, Vizient, Leapfrog, CMS Star Ratings, and payer contracts, to help implement strategies and educate teams.
- Identify root causes, facilitate resolution, and align resources across the Northwestern Medicine network.
- Teach and coach colleagues on clinical documentation integrity and independently assist with onboarding new staff.
- Instruct the clinical documentation team and distribute updates on documentation and coding concepts, federal rule changes, and risk methodology.
- Perform medical record reviews and collect data to identify documentation issues and improvement opportunities.
- Analyze case review data to identify and communicate improvement patterns and trends.
- Collaborate with program leadership to identify physician and service-line education needs and create and present targeted education.
- Participate in strategies for reviewing and reporting DRG denials, Patient Safety Indicators, and Hospital Acquired Conditions; support monthly PSI and HAC event reporting as requested.
- Lead, plan, and coordinate clinical documentation integrity onboarding at business-unit and system levels.
- Assist managers with interviewing, requisition posting, and onboarding coordination.
- Develop and evaluate orientation and training programs and monitor competencies.
- Support the development of new and existing clinical documentation integrity staff, contribute to staff development plans, and provide input for annual performance reviews.
- Support mortality review processes and ensure timely review, tracking, and reporting.
- Collaborate with managers to coordinate and write appeals in response to government and commercial denials.
- Assist program leadership with day-to-day assignments, including concurrent and retrospective reviews, work-queue management, and rounding assignments.
- Complete special projects assigned by clinical documentation program leadership.
- Track technology issues related to the review process and work with program leadership and IT to improve them.
- Assist with developing and implementing policies and workflows for clinical documentation programs.
- Serve as a clinical documentation expert and advocate in multidisciplinary settings and troubleshoot technical and process issues.
- Participate in at least one Northwestern Medicine Clinical Documentation committee, with manager approval, and in hospital committees or task forces as approved.
Benefits
- Competitive benefits, including tuition reimbursement, loan forgiveness, and 401(k) matching.
- A range of benefits intended to support employees’ physical, emotional, and financial well-being and provide protection for unexpected life events.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
