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Clinical Quality Documentation Specialist, Full-time, Days, Hybrid ($4,000 sign-on bonus)

Company: 
Northwestern Medicine
City: 
Chicago
State: 
Illinois
Employment type: 
Full time
Remote Position: 
No
Required degree level: 
Other

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)
  • Matching 401(k)
  • Excellent medical, dental and vision coverage
  • Life insurance
  • Annual Employee Salary Increase and Incentive Bonus
  • Paid time off and Holiday pay


Pay Starting at: $34.28+ per hour based on experience

Northwestern Medicine is powered by a community of colleagues who are purpose-driven and committed to our mission to deliver world-class care. Here, you'll work alongside some of the best clinical talent in the nation leading the way in medical innovation and breakthrough research with Northwestern University Feinberg School of Medicine.

We recognize where you've been, and we support where you're headed. We celebrate diverse perspectives and experiences, which fuel our commitment to equity and culture of service.

Grow your career with comprehensive training and development opportunities, mentorship programs, educational support and student loan repayment.

  • Create the life you envision for yourself with flexible work options, a Reimbursable Well-Being Fund and a Total Rewards package that support your physical, mental, emotional and financial well-being.
  • Make a difference through volunteer opportunities we offer in local communities and drive inclusive change through our workforce-led resource groups.


From discovery to delivery, come help us shape the future of medicine.

Description

The Clinical Quality Documentation Specialist I reflects 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 I 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 I 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 I acts as a change agent to systematically drive and implement change as prioritized by Clinical Documentation Leadership and Senior Clinical and Senior Quality leadership and/or through the quality and safety committees. Participates in performance improvement initiatives, receives and monitors control plans and data trends under the purview of the Clinical Documentation and Clinical Quality Programs and in collaboration with clinical interdisciplinary quality committees and physician practices. Key to this role is the ability to compel changes in documentation through in-person interaction to facilitate accurate representations of patient characteristics within the medical record so that process and outcome measures based on documentation reflect performance accurately.

Responsibilities:

  • In partnership with Clinical Documentation Leadership and the Medical Directors of Clinical Documentation, maintains integrated relationships with business unit and system physician and administrative leaders to advance quality metrics through front-line documentation efforts.
  • Rounds daily with physician and advanced practice providers (APPs) in assigned service line(s) or business units 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.
  • Partners with operational and medical leadership in a given service line or business unit to identify, develop and implement successful communication and education, to engage physicians and improve processes and 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.
  • Basic understanding of clinical documentation through the lens of local and national quality and ranking methodologies, including but not limited to, U.S. News and World Report, Vizient, Leapfrog, the CMS Star Rating, and payer contracts and assists the Managers of Clinical Documentation in execution of and maintenance of key strategies to effect change.
  • Understands the basics of leveraging their NM network to initiate conversations, identify root causes and resolution, and align resources.
  • 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 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 colleagues and 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 in a minimum of one NM Clinical Documentation committee as approved by Manager, Clinical Documentation
    • 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, including special projects.
    • Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct.


Qualifications

Required :

  • Registered Nurse in the State of Illinois
  • Bachelor's or Master's degree in nursing
  • Minimum 2 years of experience of bedside nursing care and participation in clinical quality, patient safety, or related initiatives with evidence of effective change management skills.
  • 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 :

  • Master's Degree
  • Five years' experience in medical/ surgical, critical care, intensive care or emergency care preferred


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.

While each of our 11 hospitals and more than 200 locations has a unique story, Northwestern Medicine is unified under one vision: to put patients first in everything that we do. Anchored by Northwestern Memorial Hospital in downtown Chicago, Northwestern Medicine brings academic medicine into the heart of local communities across the suburbs and beyond, close to where our patients live and work.

Northwestern Medicine is dedicated to providing the most advanced health care to the communities and patients we serve. The Northwestern Medicine clinical and administrative staff, medical and science faculty, and medical students come together every day with a shared commitment to superior quality, academic excellence, scientific discovery and patient safety.

Northwestern Medicine has:

  • More than 33,000 employees dedicated to exceptional service and care
  • More than 4,400 aligned physicians, including faculty, residents and scientists, offering treatment informed by the latest research from Northwestern University Feinberg School of Medicine
  • 6 hospitals honored by the Magnet® Recognition Program for meeting the highest standards for patient care and nursing excellence
  • Hundreds of locations throughout the Chicagoland area

CULTURE

Our Mission, Vision and Core Values

Whether directly providing patient care or supporting those who do, every Northwestern Medicine employee has an impact on the quality of the patient experience and the level of excellence we collectively achieve. This knowledge, expressed in our shared commitment to a single, patient-focused mission, unites us.

Mission

Northwestern Medicine is a premier integrated academic health system where the patient comes first.

  • We are all caregivers or someone who supports a caregiver.
  • We are here to improve the health of our community.
  • We have an essential relationship with Northwestern University Feinberg School of Medicine.
  • We integrate education and research to continually improve excellence in clinical practice.
  • We serve a broad community and strive to bring the best in medicine closer to where patients live and work.

Vision

To be a premier integrated academic health system that will serve a broad community and bring the best in medicine—including breakthrough treatments and clinical trials enhanced through our affiliation with Northwestern University Feinberg School of Medicine—to a growing number of patients close to where they live and work.

Values

Patients first: Putting our patients first in all that we do

Integrity: Adhering to an uncompromising code of ethics that emphasizes complete honesty and sincerity

Teamwork: Team success over personal success

Excellence: Continuously striving to be better

  • “Best Place to Work for Disability Inclusion” (2022): Top score and designated as “Best Place to Work for Disability Inclusion” by the Disability Equality Index
  • “Best Place to Work for Disability Inclusion” (2021): Top score and designated as “Best Place to Work for Disability Inclusion” by the Disability Equality Index

 

 

Accommodations:
Vision Accommodations, Hearing Accommodations, Neurodiversity, Learning, Mental Health, Mobility