Clinical Quality Documentation Specialist I
Core
Facilitates improvement in the completeness and accuracy of quality data and outcomes through extensive interaction with physicians, nursing staff, and clinical coders to advance problem analysis and creative process redesign for clinical documentation.
Role type
Senior IC clinical quality documentation specialist
Builds
Accurate representations of patient characteristics within the medical record to reflect performance accurately
Domain
Healthcare / Clinical Quality Improvement
Required skills
Clinical nursing expertise, change management, data analysis, root cause analysis, interdisciplinary collaboration, regulatory compliance, performance improvement, communication, conflict management, negotiation
Preferred skills
Master's degree, 5+ years in medical/surgical/critical care/emergency care
Technologies
Electronic health records, data collection tools, quality reporting platforms
Responsibilities
Round daily with physicians and APPs to ensure accurate documentation; perform daily medical record reviews; analyze quality and patient safety data (HACs, PSIs, CMI, Expected mortality); identify documentation issues and opportunities for improvement; present updates to leadership and committees; collaborate with clinical coding teams; participate in clinical documentation committees and task forces.
Seniority
Mid-level, hands-on IC
