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Lead Clinical Quality Document Specialist, Full-time, Days

Location Chicago, Illinois Business Unit Northwestern Medicine Corporate Job REQID 44180 Job Function Quality/Business Development/Process Improvement Shift Day Job (1st) Apply Now

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?


The  Lead Clinical Quality Document 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.


  • 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.
  • Participates in unit/departmental/divisional or hospital committees/task forces as approved by manager/director.
  • AA/EOE



  • 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.


  • Certification in Clinical Documentation (ACDIS).
  • Master's degree.

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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