Nurse Auditor, Clinical Documentation Specialist, Full-Time, Days

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Nurse Auditor, Clinical Documentation Specialist, Full-Time, Days Location Chicago, Illinois Business Unit Northwestern Medicine Corporate Job REQID 76568 Job Function General Healthcare Shift Day Job (1st) Pay rates are dependent upon experience. The minimum starting hourly rate for this position is $38.06

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?

Benefits

• Annual Employee Incentive Bonus
• $6,000 Student Loan Repayment ($5,000 part-time)
• $5,250 Tuition Reimbursement per year ($3,000 part-time)
• $1,000 Professional Development per year ($500 part-time)
• $250 Wellbeing Fund per year

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?

Description

The Nurse Auditor, Clinical Documentation Specialist 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 Nurse Auditor, Clinical Documentation Specialist 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 Nurse Auditor, Clinical Documentation Specialist is responsible for maintaining quality work queues and quality reports, advanced and complex project work that includes, but is not limited to, Risk Adjustment, Mortality Review, Hospital Acquired Condition (HAC) and Patient Safety Indicator (PSI) Review, Quality Abstraction and Analysis, and/or special and non-traditional project work. Incumbents to this role have a mastery of advanced clinical documentation integrity and quality concepts, coupled with the ability to consistently identify root causes and deliver measurable results.Â

The key to this role is the ability to lead and facilitate quality initiatives and external rankings initiatives. The Nurse Auditor, Clinical Documentation Specialist solves complex problems and adds new perspectives to existing solutions. The Nurse Auditor, Clinical 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. Â

Responsibilities:

• 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 effect change.Â
• Partners with Clinical Documentation leadership and Clinical Documentation Medical Directors to coordinate, maintain, and execute advanced project work that includes, but is not limited to, Mortality Review, HAC/PSI Review, Quality Abstraction and Analysis, and/or special and non-traditional project work.Â
• Partners with NM departments that includes but is not limited to: IT; Analytics; and Innovation to design and implement new and advanced workflow solutions.
• Partners with third-party consultants/partners to contribute to workflow and methodology build and refine as necessary.Â
• Communicates with ancillary departments, such as Clinical Nutrition and Wound Care, as appropriate, given potential patient learnings identified through artificial intelligence mechanisms.Â
• Validates administrative claim data that includes but is not limited to: point of origin; admission source; and discharge disposition and performs corrective action and follow-up as appropriate.
• Documents interventions and performs data collection activities. Â
• Responsible for maintenance of quality reports and quality work queues. Ensures that all quality audits are completed accurately, objectively, and in a timely manner.
• Completes all necessary documentation to support audit work, communicates audit findings with staff and leaders to assist in the evaluation process and staff development purposes, with a specific focus on quality improvement, risk adjustment, and external rankings
• Identifies and escalates trends or issues with processes to appropriate leadership for resolution.
• In partnership with the Managers of Clinical Documentation and the Director of Clinical Documentation, designs and maintains integrated relationships with business unit and system physician and administrative leaders to advance quality metrics through front-line documentation efforts.
• Leverages NM network to initiate conversations, identify root causes and resolutions, and align resources.Â
• 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.
• 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.Â
• 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.Â
• 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.
• Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct.

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.Â
• Applies knowledge of professional nursing standards, best practices, and interdisciplinary collaboration to advance problem analysis and resolution and creative process redesign.

Qualifications

Required:

• Registered Nurse in the State of Illinois
• Bachelor’s or Master’s degree in nursing
• 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.Â
• 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 of experience in medical/ surgical, critical care, intensive care or emergency care

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.

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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.

We are committed to providing reasonable accommodations to qualified individuals with disabilities. To request a reasonable accommodation at any step in our application or interviewing process, please email and a Human Resources representative will connect with you to discuss next steps.

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