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Clinical Documentation Nurse - Quality

Role overview

Qualifications

  • Current IL Nursing License (RN)
  • Minimum of two years direct clinical experience
  • Quality Improvement experience
  • Two years’ experience with TJC/CMS core measures/NSQIP abstraction

Responsibilities

  • Provide abstraction and analysis of clinical medical record documentation to support clinical measures of care
  • Educate clinical teams and leaders of documentation needs related to clinical measures to guide improvement efforts
  • Engage clinical teams in improvement initiatives through ongoing monitoring and feedback of performance
  • Continual education pertaining to abstraction specifications and inter-rater reliability testing among colleagues

Key facts

Hard skills

Other skills

  • Communication

About the company

UChicago Medicine logo

UChicago Medicine

  • Hospitals & Health Systems
  • 5,001–10,000
The University of Chicago Medicine has been at the forefront of medicine since 1927, when we cared for our first patients. Our mission is to provide superior health care in a compassionate manner, ever mindful of each patient's dignity and individuality. To accomplish our mission, we call upon the skills and expertise of all who work together to advance medical innovation, serve the health needs of the community, and further the knowledge of those dedicated to caring. As one of the nation’s leading academic medical institutions, UChicago Medicine comprises the Medical Center, Pritzker School of Medicine and the Biological Sciences Division. Its main Hyde Park campus is home to the Center for Care and Discovery, Bernard Mitchell Hospital, Comer Children’s Hospital and the Duchossois Center for Advanced Medicine. It also has a 108,000-square-foot facility in Orland Park as well as an outpatient clinic in Chicago's South Loop, as well as affiliations and partnerships that create a regional network of doctors in dozens of Chicago-area communities. UChicago Medicine offers a full range of specialty-care services for adults and children through more than 40 institutes and centers including an NCI-designated Comprehensive Cancer Center. It has 805 licensed beds, nearly 850 attending physicians, about 2,500 nurses and over 1,100 residents and fellows. Harvey-based Ingalls Health joined UChicago Medicine’s network in 2016.

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Job description

Be a part of a world-class academic healthcare system at UChicago Medicine as a Clinical Documentation Nurse - Quality for the Office of External Assessments. This position will be primarily a remote work from home opportunity but must reside in Chicagoland.

The Clinical Documentation Nurse – Quality supports clinical performance through accurate abstraction, review, and reporting of clinical documentation to support quality improvement, accreditation, regulatory, and patient safety initiatives. The CDN uses established measure specifications, data definitions, and flowcharts to accurately review and abstract data. The successful candidate engages with clinicians and others to clarify documentation, identify gaps or variances, and provide meaningful feedback that supports accurate clinical documentation and evidence-based care.

Essential Job Functions

  • Provide abstraction and analysis of clinical medical record documentation to support clinical measures of care

  • Educate clinical teams and leaders of documentation needs related to clinical measures to guide improvement efforts

  • Engage clinical teams in improvement initiatives through ongoing monitoring and feedback of performance

  • Continual education pertaining to abstraction specifications and inter-rater reliability testing among colleagues

  • Other duties as assigned by manager

Required Qualifications

  • Current IL Nursing License (RN)

  • Minimum of two years direct clinical experience 

  • Quality Improvement experience

Preferred Qualifications

  • Two years’ experience with TJC/CMS core measures/NSQIP abstraction

  • Knowledge of acute care regulatory/accreditation requirements 

Position Details

  • Job Type/FTE: Full-Time  
  • Shift: Days
  • Job Location: Remote 
  • Unit/Department: Office of External Assessments
  • CBA Code: Non-Union

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