Lead Clinical Quality Documentation Specialist

Northwestern Medicine; Winfield (IL); On-site; USD 110,000 - 140,000; Full time

Job summary

Northwestern Medicine is seeking a Lead Clinical Quality Documentation Specialist to lead CDI initiatives, coach staff, and align documentation practices with clinical quality goals. The role requires nursing leadership, strong data analysis, and collaboration with executives across NM.

The position emphasizes improving documentation accuracy, value-based outcomes, and governance through expert CDI guidance and education. Travel may be required to support NM needs.

Qualifications

• Registered Nurse in Illinois.
• Bachelor’s or Master’s degree in nursing.
• Minimum of 3 years of Clinical Documentation Integrity experience.
• Minimum 2 years of bedside nursing with quality/patient safety initiatives.
• Current Certification in Clinical Documentation (ACDIS)
• Strong leadership and change management skills.
• Analytical skills to interpret clinical data.
• Strong interpersonal and communication skills.
• Proficient with common computer applications.

Responsibilities

• Lead Clinical Documentation Integrity initiatives across NM to support strategic goals.
• Collaborate with CDI Managers, Director, and Medical Director leadership.
• Coach and mentor CDI staff; drive onboarding and training programs.
• Oversee documentation reviews, data collection, and trend analysis for improvements.
• Support DRG denials review, PSI/HAC reporting, and policy development.

Skills

Clinical Documentation

Leadership

Analytical skills

Communication

Problem solving

Education

Bachelor’s or Master’s in nursing

Tools

Microsoft Office

Job description

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 accurately and cogently reflect patterns and trends that require improvement.
• Collaborates with Clinical Documentation program leadership to determine individual physician and/or service line educational needs.
  • Creates and presents targeted physician education in collaboration with Clinical Documentation program leadership.
• Participates in key strategies for the review and reporting of DRG denials, Patient Safety Indicators (PSIs) and Hospital Acquired Conditions (HACs) as assigned.
  • Supports the monthly report-out of PSI and HAC events at each business unit as requested.
• Leads, plans, and coordinates the Clinical Documentation Integrity onboarding process at the business unit and system level.
  • 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.
• Supports the growth and development of new and existing CDI staff.
  • Collaborates with manager on development plans for individual staff and provides input for annual performance reviews.
• Supports the mortality review process at each business unit and ensure timeliness in review, tracking, and reporting.
• Collaborates with manager to coordinate and write appeals in response to government and commercial denials.
• Assists Clinical Documentation program leadership in managing day-to-day assignments, including concurrent and retrospective review work, work-queue management, and rounding assignments.
• Assists with and completes special project work as assigned by Clinical Documentation program leadership.
• Tracks technology issues related to review process and works closely with Clinical Documentation program leadership and IT to improve upon them.
• Assists in Policy development and implementation related to Clinical Documentation programs and workflow.
• Serves as clinical documentation expert and advocate in multi-disciplinary settings as needed.
  • Troubleshoots technical and process issues as they arise

Additional Functions

• Participates in a minimum of one NM Clinical Documentation committee as approved by Manager, Clinical Documentation
• Participates in hospital committees/task forces as approved by manager/director.

Qualifications

Required

• Registered Nurse in the State of Illinois
• Bachelor’s or Master’s degree in nursing
• Minimum of 3 years of Clinical Documentation Integrity experience
• 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.
• Current Certification in Clinical Documentation, such as the Association of Clinical Documentation Integrity Specialists (ACDIS)
• Demonstration of advanced clinical expertise
• 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

Preferred

• Master’s degree in relevant field
• Microsoft office suite skills relevant to the role

Equal Opportunity

Northwestern Medicine is an equal opportunity employer (disability, VETS) 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.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events.

Please refer to the Benefits Eligibility by Employment Classification to determine benefits eligibility for job postings.

If sign-on bonus is included in a job posting eligibility is as followed: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign-on bonus. Exception: New graduate internal employees seeking their first licensed clinical position as a Registered Nurse at NM may be eligible.