Clinical Quality Documentation Specialist

Benefits

• $10,000 Tuition Reimbursement per year ($5,700 part-time)
• $10,000 Student Loan Repayment ($5,000 part-time)
• $1,000 Professional Development per year ($500 part-time)
• $250 Wellbeing Fund per year($125 for part-time)
• Annual Employee Merit Increase and Incentive Bonus
• Paid time off and Holiday pay

Description

The Clinical Quality Documentation Specialistreflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The Clinical Quality Documentation Specialist position facilitates improvement in the overall completeness and accuracy of quality data and outcomes through extensive interaction with physicians, nursing staff, interdisciplinary quality committees, multidisciplinary teams and clinical coders. The Clinical Quality Documentation Specialist applies clinical expertise, knowledge of the national quality agenda, professional nursing standards, current research, best practices, and interdisciplinary collaboration to advance problem analysis and creative process redesign for clinical documentation. The Clinical Quality Documentation Specialist acts as a change agent to systematically drive and implement change as prioritized by senior clinical leadership through the quality and safety committees. This role brings leadership and communication skills to interdisciplinary quality/patient safety efforts. The Specialist participates in performance improvement initiatives, receives and monitors control plans and data trends under the purview of the Clinical Quality Program and in collaboration with clinical interdisciplinary quality committees and physician practices.

Responsibilities:

• Partners with operational and medical leadership in a given service line to identify, develop and implement successful communication and education, to engage physicians and improve processes and outcomes.
• Rounds daily with physician and mid-level providers in assigned service line(s) to ensure appropriate and accurate documentation in the medical record. Ensures the level of services and acuity of care will accurately be reflected in quality outcomes.
• Performs daily medical record reviews in assigned service line(s). Performs data collection activities to identify documentation issues, quality issues, and opportunities for improvement in patient care and services.
• Analyzes quality and patient safety data to identify patterns in the management of patient care and services using reported 1.) Hospital acquired conditions, 2) Patient safety indicators, 3) Case Mix index, and 4) Expected mortality.
• Collaborates with the Clinical Quality Team and the Clinical Quality Medical Directors to model, teach and improve upon the culture of safety with shared improvement in all venues.
• Presents updates to operational and medical leadership, attending and resident physicians and interdisciplinary quality committees.
• Communicates effectively and collaborates with the Clinical Coding Team. Fosters an environment to execute a shared vision in creating a model of best practice in the accurate reporting of patient diagnoses, comorbid conditions and treatment rendered.
• Professional Development and Education:
  • Masters evidence and literature in relevant clinical area, discipline, and improvement science, including Clinical Quality improvement, patient safety, human factors, failure modes, root cause analysis, and related performance and safety resources.
  • Applies knowledge of professional nursing standards, best practices, and interdisciplinary collaboration to advance problem analysis and resolution and creative process redesign.
• Other:
  • Participates on departmental and hospital committees and task-forces as assigned.
  • Participates in concurrent performance improvement activities and on-going review activities.
  • Performs other job related duties as requested.
  • Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct.

Qualifications

Required:

• Licensed Registered Nurse (R.N.) in the State of Illinois
• Bachelor of Science Degree in Nursing
• Demonstration of advanced clinical expertise
• Must possess and consistently demonstrate:
  • Strong interpersonal, communication, conflict management, diplomacy and negotiation skills.
  • Proven leadership to affect positive Clinical Quality outcomes.
  • Analytical skills necessary to independently collect analyze and interpret clinical data.
  • Basic computer skills and willingness to learn computer applications relative to this position

Preferred:

• Five years of experience in medical/surgical, critical care, intensive care, or emergency care

Equal Opportunity

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.