UW Medicine - Northwest Hospital & Medical Center

  • Clinical Documentation Specialist - Quality Improvement

    Posted Date 1 month ago(1 month ago)
    Full Time
    8713 Quality Improvement
    1st, Days
    Job Location
    New Grads?
  • Overview

    Join our award-winning team at UW Medicine - Northwest Hospital & Medical Center.  We're proud of the acclaim we've received for our excellence in patient care and safety. Among the local, regional and national recognition we've received are:

    • The Distinguished Hospital for Clinical Excellence Award
    • The Emergency Medicine Excellence Award
    • This is the second consecutive year Northwest Hospital has achieved both the Spine Surgery Excellence Award and a ranking among the top 10 percent in the nation for spine surgery.
    • The Stroke Care Excellence Award
    • Winner of the Health Grades Distinguished Hospital Award for Patient Safety for the last three years in a row, we’re also one of the safest places to get care – among the top 5% in the country.

    UW Medicine includes Harborview Medical Center, UW Medical Center, Northwest Hospital & Medical Center, Valley Medical Center, UW Neighborhood Clinics, UW Physicians, UW School of Medicine and Airlift Northwest. 

    Northwest Hospital & Medical Center is a full-service, non-profit community hospital, offering comprehensive medical, surgical and therapeutic services.  With 281 beds, more than 1900 employees and a world-class medical staff, we provide innovative, technologically advanced care on a patient-friendly, easy-access campus just north of Seattle. 

    Our staff not only enjoys outstanding benefits and professional growth opportunities, but also an environment noted for diversity, community involvement, intellectual excitement, artistic pursuits, and natural beauty. 

    As a UW Medicine - Northwest Hospital & Medical Center employee, you will enjoy generous benefits and work/life programs.


    We’re interested in learning more about you and appreciate your taking the time to apply online. UW Medicine - Northwest Hospital & Medical Center is committed to employing a diverse workforce. EOE


    UW Medicine – Northwest Hospital and Medical Center is an Affirmative Action/Equal Opportunity Employer. We welcome job applications from qualified individuals without regard to race, color, creed, religion, ancestry, national origin, age, sex, pregnancy, marital status, physical or mental disability, or any other protected characteristic. Minorities, women, disabled persons, and veterans are encouraged to apply


    Northwest Hospital has an opportunity for a RN Clinical Documentation Specialist.  This role will allow you to apply your critical thinking and problem solving skills in a setting outside of traditional bedside care.  The Clinical Documentation Specialist RN collaborates with Clinicians to facilitate complete and compliant documentation that accurately reflects a patient’s severity of illness, risk of mortality, and level of services rendered.

    In this position you will:

    • Perform extensive medical record review and act as a liaison between Clinicians and coding professionals.
    • Create a clinically credible and compliant clarification/query when opportunities for diagnosis validation or incomplete diagnoses are identified
    • Ensure that pertinent conditions and treatments are documented in language that allows for appropriate DRG assignment and reimbursement.
    • Keep current on knowledge of pathophysiology and disease process.
    • Learn about how DRG assignments are made and how quality metrics such as Value Based Purchasing affect the Clinical Documentation Improvement Program.
    • Educate Clinicians and all members of the care team regarding the impact that clinical documentation has on measuring and reporting outcomes related to patient care, physician practice, and the medical center.


    Education Background

    • Bachelor of Science in Nursing required.  Additional years of relevant experience may be substituted for degree at the discretion of the Director.

    Licensure, Registration, Certification 

    • Registered Nurse with current Washington State license.

    Special Training/Skills

    • Knowledge of Pathophysiology and Disease Process.
    • Ability to be self-directed with excellent organizational, analytical writing and interpersonal skills and ability to work through issues in a professional manner
    • Microsoft Office skills:  Word, Excel, Outlook.
    • Critical thinking, problem solving and deductive reasoning skills
    • Ability to build and maintain positive, supportive working relationships and be a strong team player.
    • Demonstrates ability to achieve consensus and make decisions in group setting.

    Work Experience 

    • Requires at least five years recent hospital experience, preferably in ICU, CCU and/or Med/Surg.

    Physical Abilities

    • Able to sit for extended periods of time.  Able to operate a computer.
    • Must be able to handle a fluctuating workload
    • This job requires ability to communicate clearly in English (verbal and written) with all stakeholders (staff members, clinicians, practitioners and the general public).

    Physical Demand Level:  Sedentary

    In an 8-hour workday, must be able to-


    Lift / Carry 10 pounds occasionally


    As required, must be able to-

    Sit, Stand, Walk, Bend, Squat, Kneel, Crawl, Climb and Reach above shoulders

    Push and Pull

    Perform fine motor functions

    Must possess functional vision, hearing, and speech in order to communicate effectively with clients, client advocates, and staff.


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