Northwestern Medicine · 2 days ago
Clinical Quality Documentation Specialist, Full-time, Days, Hybrid (Sign-on bonus eligible)
Palos Heights, IL
Full-time
Hybrid
Entry, Mid Level
2+ years expNorthwestern Medicine is a leader in the healthcare industry, committed to providing quality patient care. The Clinical Quality Documentation Specialist I plays a crucial role in improving the completeness and accuracy of quality data through collaboration with various healthcare professionals, ensuring that documentation reflects patient characteristics accurately.
Emergency MedicineHealth CareHospitalMedicalNutritionRehabilitation
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
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
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
Qualification
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
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
Benefits
Tuition reimbursement
Loan forgiveness
401(k) matching
Lifecycle benefits
Company
Northwestern Medicine
Northwestern Medicine is the collaboration between Northwestern Memorial HealthCare and Northwestern University Feinberg School of Medicine around a strategic vision to transform the future of health care.
10001+ employees
H1B Sponsorship
Northwestern Medicine has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (75)
2024 (66)
2023 (70)
2022 (78)
2021 (35)
2020 (39)
Funding
Current Stage
Late StageTotal Funding
$25M2018-06-26Grant· $25M
Leadership Team
Howard Chrisman, MD
President and CEO
John A. Orsini, CPA
Senior Vice President and Chief Financial Officer
Recent News
Near North Health
2025-12-01
Medical Xpress - latest medical and health news stories
2025-11-18
Company data provided by crunchbase