Clinical Documentation Nurse - Quality

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

The Clinical Documentation Nurse – Quality supports clinical performance through abstraction, review, and reporting of medical record clinical documentation and billing assessment, to support initiatives related to quality improvement, accreditation, and regulatory requirements. The successful abstractor engages clinicians in measures of care and provides feedback to ensure accurate clinical documentation and evidence-based care.

Essential Job Functions

• Provide abstraction and analysis of clinical medical record documentation and hospital billing codes 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 required

Preferred Qualifications

• Minimum of two years’ experience in Utilization, Quality Assurance, or Case Management preferred
• Preferred that candidate possess credentials as a RHlT (Registered Health Information Technician), CCS (Certified Coding Specialist), or CCS-P (Certified Coding Specialist-Physician-based) through the American Health Information Management Association
• Knowledge of acute care regulatory/accreditation requirements preferred
• Discharge planning and / or Quality Improvement experience preferred

Position Details

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