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Lead Clin Qual Document Spec

Northwestern Medicine
Employment type: 
Full time
Remote Position: 
Required degree level: 

Masters the art and science of Clinical Documentation and serves as a resource and role model for staff. Works collaboratively with Clinical Documentation program leadership, providers, and staff at all levels of seniority to define and achieve common aims. Applies knowledge of professional practice, Clinical Documentation standards, best practices, and interdisciplinary collaboration to advance problem analysis and resolution and creative process redesign. Performs medical record reviews and other data collection activities that assist in identifying potential documentation issues and opportunities for improvement. Analyzes case review data to accurately and cogently reflect patterns and trends that require improvement. Tracks technology issues related to review process and works closely with Clinical Documentation program leadership and IT to improve upon them. Collaborates with manager to coordinate and write appeals in response to government and commercial denials. Collaborates with manager to assist with interviewing of new team members, posting of new requisitions, and coordination of onboarding. Develops and evaluates initial and ongoing orientation and training programs to establish and monitor competencies. Collaborates with manager on development plans for individual staff and provides input for annual performance reviews. Facilitates formal and informal education of the Clinical Documentation team. Instructs Clinical Documentation team on Clinical Documentation concepts, federal rule changes, and risk methodology updates. Assists in Policy development and implementation related to Clinical Documentation programs and workflow. Collaborates with Clinical Documentation program leadership to determine individual physician and/or service line educational needs. Creates and presents targeted physician education. Champions new initiatives and helps in unit/departmental or hospital-wide committees/task forces. Maintains a dashboard to reflect impact of Clinical Documentation on quality metrics (HACs/PSIs, Mortality, LOS, etc.). Collaborates with Clinical Documentation program leadership to prepare submissions for journal articles and /or local and national conferences. Additional Functions: Participates in unit/departmental/divisional or hospital committees/task forces as approved by manager/director. EOE including Disabled and Veterans.

Required: Current license as a Registered Nurse State of Illinois Professional Nurse. 2+ years experience in Clinical Documentation. BSN with a minimum of 2-5 years clinical advanced experience. Demonstration of advanced clinical expertise required. 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. Strong computer skills and familiar with computer applications relative to this position. Desired: Certification in Clinical Documentation (ACDIS). Masters Degree.

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

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