Lead Clinical Quality Documentation Specialist, Full-time, Days (Hybrid)

Company Description

At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better healthcare, no matter where you work within the Northwestern Medicine system. At Northwestern Medicine, we pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, we take care of our employees. Ready to join our quest for better?

Job Description

The Lead Clinical Quality Documentation Specialist reflects the mission, vision, and values of Northwestern Medicine (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 Lead Clinical Quality Documentation Specialist is a Registered Professional Nurse and expert Clinical Documentation Specialist, responsible for leading clinical documentation integrity efforts in support of NM and business unit strategic goals under the direction of Clinical Documentation program leadership. The Lead Clinical Quality Documentation Specialist is proficient in clinical documentation integrity and quality concepts and is responsible for initiatives leading to cross-regional change and program enhancements.  The Lead Clinical Quality Documentation Specialist anticipates issues, interprets internal / external issues, and helps lead problem resolution by aligning resources, recommending best practices, and implementing related solutions.  Key to this role is also the ability to lead and facilitate verbal and written conversations with key stakeholders across NM as well as oversee and coach clinical documentation team members through challenging projects or issues.  The Lead Clinical Quality Documentation specialist is a change agent that systematically drives and implements documentation and coding program improvements that leads to accuracy and improved performance to advance financial and quality outcomes for NM and each business unit.  May require travel to support the business needs of Northwestern Medicine.  The Lead Clinical Quality Documentation Specialist applies advanced knowledge of the national quality agenda and clinical documentation integrity best practices to advance problem analysis and creative process redesign for Northwestern Medicine.  
 

Responsibilities:

• Masters the art and science of Clinical Documentation and serves as a resource and role model for staff. 
• Collaborates with Managers of Clinical Documentation, the Director of Clinical Documentation, and Medical Director leadership to align clinical documentation integrity work efforts to the extent possible throughout NM.
• Collaborates with leaders across NM to advance Clinical Documentation work efforts.  
• Key Stakeholders include, but are not limited to, Managers of Clinical Documentation, Director of Clinical Documentation, System Clinical Coding Leaders, Business Unit and System Clinical Quality Managers and Directors, Business Unit Nutrition Managers, Business Unit Clinical Managers.
• Scope includes all functions which support documentation within the patient’s medical record.  
• Scope includes all practitioners, clinicians and others participating in delivering or supporting patient care, including those privileged through the medical staff, trainees, students, employees, volunteers.
• Applies knowledge of professional practice, Clinical Documentation standards, best practices, and interdisciplinary collaboration to advance problem analysis and resolution and creative process redesign.
• Advanced 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 implementing key strategies to teach and deploy the team in the manner necessary to effect change.  
• Leverages NM network to initiate conversations, identifies root causes and resolution, and aligns resources.
• Teaches and coaches colleagues on all areas of clinical documentation integrity and independently assists in the onboarding of new staff.   
• Instructs Clinical Documentation team and distributes updated information on Clinical Documentation and Coding concepts, federal rule changes, and risk methodology updates.
• 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 accuratel