Clinical Documentation Nurse - Quality

Clinical Documentation Nurse - Quality

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.

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