Manager - Clinical Documentation, Full-Time, Days - #99785

Northwestern Memorial Healthcare

Date: 04/19/2022 12:00 PM

City: Palos Heights, Illinois

Contract type: Full Time

Work schedule: Full Day

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 Manager, Clinical Documentation 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 Manager, Clinical Documentation is responsible for leading clinical documentation integrity efforts in support of NM and business unit strategic goals. This role is also responsible for managing relationships with key stakeholders at multiple business units to advance financial and quality outcomes for NM and each business unit. Functional areas of responsibility include clinical documentation at more than one business unit to assure effective workflow process design for clinical documentation interventions that promote accurate and timely documentation. 

Key to this role is the ability to compel changes in documentation to facilitate accurate representations of patient characteristics within the medical record so that process and outcome measures based on documentation reflect performance accurately. This position requires frequent travel to support the business needs of Northwestern Medicine. The Manager, Clinical Documentation reports to the Director, Clinical Documentation.

In collaboration with the Director of Clinical Documentation and other leadership, this role will develop, implement, monitor and achieve the annual business unit and system level Clinical Documentation Plans.


  • Lead, plan, and coordinate the Clinical Documentation Integrity programs at the business unit and system level, in collaboration with the Director of Clinical Documentation and the Medical Director(s) of Clinical Documentation at each business unit.
    • Key Stakeholders include Business Unit and System Directors, Chief Financial Officers, Chief Nurse Executives, Regional and System Vice Presidents, and Chief Medical Officers.
    • 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.
  • Manage staff at multiple hospital locations and maintain high levels of staff engagement and performance to meet department objectives.
  • Design and lead integrated relationships with business unit and system physician and administrative leaders to advance quality metrics through front-line documentation efforts; pairing clinical documentation team members with physician and advanced practice providers through rounding initiatives and/or an in-person cadence.
  • Partner with Key Stakeholders (as above), Clinical Quality, Coding, Corporate Integrity and Compliance, Value Based Care, Health Information Management (HIM), and other leaders to understand the national quality agenda, the annual system and regional key initiatives, the Inpatient Quality Composite goals, annual employee goals, and other business unit and system improvement initiatives to incorporate such goals and monitoring plans into the annual Clinical Documentation Quality Improvement plan as appropriate. 
  • Understand 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 implement key strategies to teach and deploy the team in the manner necessary to effect change. 
  • Implement initiatives to support advancing the work of NM business units and system function goals, as outlined above. 
    • As assigned, assume leadership in advancing these programs and projects at the business unit or system level
  • Advance the standard of quality across NM through innovation, learning and shared deployment of best practices.
  • Facilitate resolution of issues among key partners and lead complex conversations, as needed, between clinical documentation, coding, care coordination, physicians and/or other leaders to bring closure to issue at hand.
  • Design, lead and adhere to the annual Clinical Documentation Plan.
  • Lead, develop, and identify key strategies for the review and reporting of DRG denials, Patient Safety Indicators (PSI) and Hospital Acquired Conditions (HAC) as assigned.
  • Support the monthly report-out of PSI and HAC events at each business unit as requested.
  • Support the mortality review process at each business unit and ensure timeliness in review, tracking, and reporting.  
  • Design, lead, implement, teach and monitor NM clinical documentation integrity practices, risk adjustment practices, policies, protocols and methodologies.
  • Design and lead department system Clinical Documentation committees as assigned.
  • Collaborate 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.
  • Prepare monthly data reports for Key Stakeholders as requested.
  • Present to and / or create presentations for Key Stakeholders as requested.    
  • Support and prepare materials for the monthly Clinical Documentation Improvement Committee Meeting. 
  • Design, lead, implement, teach and monitor use of technology and data driven approaches to achieving the most accurate clinical documentation.
  • Identify, develop, and implement key strategies to leverage the electronic health record (EHR) and other tools to facilitate accurate representations of patient acuity, severity of illness, risk of mortality, and risk adjustment within the medical record. 
  • Monitor internal and external trends, concurrently and retrospectively, to identify priorities and implement strategies for improvement. 
  • Collaborate with and lead engagements with external vendors that support clinical documentation education, data analysis, and technology.
  • Design, implement and monitor internal and external performance data and metrics of individual direct reports. 
  • Implement surveillance and reporting oversight to identify areas of concern and strength.
  • Analyze and monitor NM Clinical Documentation Integrity Account WQs to maintain revenue cycle standards/goals.
  • Analyze and monitor budgets monthly to ensure fiscal responsibility.
  • Assure and support appropriate public transparency and reporting of quality data.
  • Assure and support training for the Clinical Documentation Team(s) across NM.
  • Recruit and develop staff, teach/orient/train, manage financial and human resources efficiently and effectively.
  • Collaborate effectively across the system with direct reports, colleagues, key stakeholders, and key partners. 



  • Registered Nurse in the State of Illinois
  • Bachelor’s or Master’s degree in nursing
  • Minimum 5 years of experience of bedside nursing care and participation in clinical quality, patient safety, or related initiatives with evidence of effective change management skills. 
  • Project management, facilitation, and analytical skills
  • Statistics, quantitative and analytic skills relevant to the role
  • High level of energy and enthusiasm; flexible/adaptable – ability to work with diverse group of healthcare professionals in a matrix environment
  • Effective problem solving and multi-tasking, verbal and written communication skills


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



Additional Information

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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