Physician Assistant or Nurse Practitioner - Thoracic Surgery, Quality, Clinical Documentation (Outpatient), Full-time, Days

About the role

Northwestern Medicine has an exciting opportunity for either a Nurse Practitioner or a Physician Assistant to work in their Outpatient Thoracic Surgery, Quality, Clinical Documentation department.

Responsibilities

• Maintain professional engagement & collaboration with the following: Active, valued participation in M&M and multidisciplinary review. Effective and reliable performance on the periodic occasions when clinical coverage is requested. Engage with respective CDI party (inpatient v. ambulatory) Engage with PB Coding, Inpatient coding, and Rev Cycles at NM Engage with Physician and APP Support Staff (PASS) Team Engage with NM & CTI Quality Committee
• Comprehensive Mortality, Morbidity, and Severity Capture The APP serves as the institute's accountable owner for the accurate capture of mortality and morbidity events, comorbid conditions, complications, and procedural detail across every quality, benchmarking, and regulatory reporting framework that measures the program. This includes — at minimum — the following platforms: ICD-10-CM and ICD-10-PCS Society of Thoracic Surgeons (STS) National Database Vizient Clinical Data Base / Resource Manager (CDB/RM) U.S. News & World Report ranking methodology MS-DRG / CC / MCC severity framework CPT coding for thoracic surgical procedures Elixhauser and Charlson comorbidity indices CMS Star Rating, Leapfrog Hospital Safety Grade, AHRQ PSIs, and CMS HACs CMS-HCC and Risk Adjustment Factor (RAF)
• Independent Documentation Refinement After Physician Consultation Conduct concurrent and retrospective chart review for all assigned cases, identifying documentation gaps, inconsistencies, missing specificity, and opportunities for more accurate severity, complication, and comorbidity capture. Discuss findings with the responsible surgeon, intensivist, or consulting physician, presenting the clinical evidence (vital signs, labs, imaging, treatment, monitoring) that supports a more complete or more specific documentation. After clinical agreement is reached, independently enter, edit, or augment documentation in the medical record to reflect the agreed clinical picture — including progress notes, problem lists, discharge summaries, and procedural documentation — within the scope of APP authorship and consistent with Northwestern Medicine policy and Medical Staff Bylaws. Generate compliant, non-leading clinical documentation queries when direct consultation is not feasible, following AHIMA/ACDIS Practice Brief standards. Reconcile final coded data with the clinical record prior to bill drop where the workflow allows, ensuring that the coded MS-DRG, CC/MCC tier, and reportable complications match the documented clinical reality.
• Application of Expert Clinical Judgment to Documentation Clinical documentation frequently permits more than one defensible level of specificity. The same clinical scenario can — entirely within the bounds of compliant practice — be documented in ways that vary materially in how completely they convey patient acuity, complexity, and the work performed. Identifying the most accurate framing in those situations is a matter of expert clinical judgment, not a clerical exercise. Apply seasoned clinical judgment to recognize when the clinical evidence in the record supports more specific, more complete, or higher-acuity documentation than what has currently been written, and partner with the treating physician to clarify the record accordingly. Where documentation is clinically defensible at multiple levels of specificity, advocate — in collaboration with the treating physician — for the framing that most accurately and completely characterizes the patient's clinical reality, the conditions actively managed, and the resources required to deliver care. Use the interpretive latitude that legitimately exists in clinical documentation to ensure that the medical record fully reflects the work being done; never document, suggest, or query for a condition that is not clinically present, supported by the record, and actively managed. Maintain a clear, auditable rationale — anchored in clinical indicators in the chart — for every documentation refinement, so that any subsequent payer, regulatory, or internal review encounters a record that is both maximally accurate and fully defensible.

Qualifications

• Master’s degree from an accredited school/college of nursing OR master's degree from an accredited Physician Assistant Program
• Current license as a Registered Nurse in the State of Illinois. Current license as an Advanced Practice Registered Nurse in the State of Illinois. Certification as an Advanced Practice Registered Nurse by a national certifying body as approved by the Illinois Department of Regulation APRN Board.