Under general supervision, the Sepsis Core Measures Abstractor and Documentation Improvement Specialist collaborates with medical, nursing, and Clinical Documentation Improvement (CDI) staff to design and execute duties. This role involves conducting thorough reviews and abstractions of patient records for concurrent reviews and working closely with the Director of Quality & Patient Safety, the Quality Outcomes Manager, and nursing and physician leaders to develop and achieve strategic goals. The specialist provides oversight for the care of sepsis patients throughout their continuum of care, ensuring comprehensive medical care and record documentation that accurately reflects clinical treatments, decisions, and diagnoses for septic inpatients. Additionally, this role supports and coaches’ providers in accurate documentation through reviews of clinical quality outcomes, conducts education and training on effective and compliant clinical documentation, and assesses documentation gaps to develop appropriate CDI educational tools to support measurable improvement.

Education

Bachelor’s degree in Nursing, Healthcare Administration, or related field required.Master’s Degree (preferred but not required)Clinical Documentation Specialist or related certification preferred.

Experience

Minimum of three years' experience in clinical documentation improvement, quality management, or a related field.Experience in a healthcare setting with a focus on sepsis care preferred.

Knowledge, Skills and Abilities

Proficient understanding of sepsis core measures, clinical guidelines, and healthcare regulatory standards.Strong analytical skills for interpreting complex clinical data and performing data analytics.Excellent verbal and written communication skills.Ability to collaborate effectively with physicians, nurses, and healthcare staff.Proficiency in using Epic electronic health records (EHR), 3M 360, Microsoft Office, and relevant software applications.Strong organizational skills with attention to detail.Ability to develop and deliver effective educational materials and training sessions.Experience in leading process and performance improvement initiatives.Advanced knowledge of nursing practice, clinical administration, anatomy, physiology, and pathophysiology.Competency in ICD-10 coding systems and clinical documentation principles.Effective problem-solving skills and experience in process improvement.Demonstrated ability to analyze complex clinical scenarios and apply critical thinking.Strong interpersonal skills to promote collaboration and teamwork.

Licensures, Certifications

Clinical experience preferred, RN license preferredCertified Clinical Documentation Specialist (CCDS) and/or Certified Coding Specialist (CCS) preferred

Physical Requirements

Ability to sit, stand, walk, concentrate and pay close attention to detail.

Working Conditions

Normal office work environment.  Opportunity to work remotely.

Patient & Workplace Safety

Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.

Patient Population

Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.

Principal Duties and Responsibilities

Conduct thorough reviews and abstraction of patient records to ensure sepsis core measure compliance.Perform data collection, management, and analytics to identify trends and support quality improvement.Develop and deliver educational materials and training on sepsis protocols and documentation requirements for clinical staff.Act as a liaison for quality outcomes across medical and surgical departments.Participate in hospital meetings, reporting findings and updates at all organizational levels.Assist in the submission of measures to federal and state agencies.Lead process and performance improvement initiatives focused on sepsis care. Collaborate with the Director of Quality & Patient Safety and Quality Outcomes Manager to develop and achieve strategic goals. Conduct regular audits to ensure compliance with sepsis core measures and regulatory standards.Facilitate interdisciplinary collaboration to enhance sepsis management and patient outcomes.Develop and monitor key performance metrics, engaging in continuous quality improvement activities. Support patient safety initiatives targeting sepsis prevention and management.Promote and implement best practices in sepsis care. Integrate technology solutions to improve sepsis identification, management, and reporting. Maintain current knowledge of sepsis guidelines and best practices through ongoing education.Performs other duties as needed.

All roles must demonstrate GBMC Values

Respect

I will treat everyone with courtesy. I will foster a healing environment.

Treats others with fairness, kindness, and respect for personal dignity and privacyListens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

Meets and/or exceeds customer expectationsActively pursues learning and self-developmentPays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

Sets a positive, professional example for othersTakes ownership of problems and does what is needed to solve themAppropriately plans and utilizes required resources for various job dutiesReports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

Works cooperatively and collaboratively with others for the success of the teamAddresses and resolves conflict in a positive waySeeks out the ideas of others to reach the best solutionsAcknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

Demonstrates honesty, integrity and good judgmentRespects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

Embraces change and improvement in the work environmentContinuously seeks to improve the quality of products/servicesDisplays flexibility in dealing with new situations or obstaclesAchieves results on time by focusing on priorities and manages time efficiently

Pay Range

$71,006.92 - $120,711.77

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.