Lead Clinical Quality Documentation Specialist

Northwestern Memorial Healthcare • Winfield, IL

4d

About The Position

The Lead Clinical Quality Documentation Specialist is a Registered Professional Nurse and expert in Clinical Documentation Integrity (CDI), responsible for leading documentation integrity initiatives in support of Northwestern Medicine and its business units’ strategic goals under the direction of Clinical Documentation program leadership. The role applies advanced knowledge of clinical documentation, quality concepts, national quality priorities, and CDI best practices to drive cross-regional improvements, accurate documentation and coding, and stronger financial and quality outcomes.

The specialist anticipates and resolves issues, aligns resources, recommends best practices, and implements solutions. The role leads and facilitates conversations with stakeholders across Northwestern Medicine and oversees, coaches, and supports clinical documentation team members. It also contributes to process redesign, staff education and onboarding, physician education, denial and mortality review activities, and documentation program policies and technology improvements. Travel may be required to meet 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 from the Association of Clinical Documentation Integrity Specialists (ACDIS).
• Advanced clinical expertise.
• Strong interpersonal, communication, conflict-management, diplomacy, and negotiation skills.
• Demonstrated leadership capable of affecting 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 skills relevant to the role.

Responsibilities

• Serve as a clinical documentation resource and role model for staff.
• Collaborate with Clinical Documentation managers, the Director of Clinical Documentation, medical director leadership, and other leaders to align and advance CDI efforts across Northwestern Medicine.
• Apply clinical documentation standards, best practices, and interdisciplinary collaboration to analyze problems, resolve issues, 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 support documentation strategies and team deployment.
• Identify root causes and resolutions, align resources, and leverage the Northwestern Medicine network to advance CDI work.
• Teach and coach colleagues on CDI, assist with onboarding new staff, and distribute updates on documentation and coding concepts, federal rules, and risk methodologies.
• Perform medical record reviews and collect data to identify documentation issues and improvement opportunities; analyze case review data for patterns and trends.
• Collaborate with program leadership to identify physician and service-line education needs and create and present targeted physician education.
• Participate in assigned 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 CDI onboarding at business-unit and system levels; assist with recruiting and onboarding activities.
• Develop and evaluate orientation and training programs, monitor competencies, support staff development, and contribute to staff development plans and annual performance reviews.
• Support business-unit mortality reviews and ensure timely review, tracking, and reporting.
• Collaborate with managers to coordinate and write appeals responding to government and commercial denials.
• Assist with day-to-day assignments, including concurrent and retrospective reviews, work-queue management, and rounding assignments.
• Complete special projects as assigned by Clinical Documentation program leadership.
• Track technology issues and work with program leadership and IT to improve the review process.
• Assist with developing and implementing policies and workflows related to 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 approved Northwestern Medicine Clinical Documentation committee and in hospital committees or task forces as approved by management.

Benefits

• Competitive benefits, including tuition reimbursement and loan forgiveness.
• 401(k) matching.
• Lifecycle benefits.
• 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: Senior