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Quality Documentation Specialist, RN

WakeMed Health & Hospitals
Raleigh, NC Full Time
POSTED ON 12/12/2025 CLOSED ON 2/7/2026

What are the responsibilities and job description for the Quality Documentation Specialist, RN position at WakeMed Health & Hospitals?

Overview: Responsible for concurrent and retrospective review of medical record documentation to collect quality data elements as specified by the CMS/TJC specifications manual or registry manual. Communicates with coding, CDI, physicians and physician extenders or nurses regarding missing, incomplete, unspecific, unclear, or conflicting documentation or impending opportunities within measured time frames. Enters findings into vendor database for hospital measures. Gathers, analyzes and shares information pertinent to documentation findings and outcomes. Provides subject matter expertise and outreach regarding measure set/registry metrics for designated population. Skills in Excel, Power Point and data visualization technology, such as Tableau, are essential. Onsite presence is an expectation as determined by manager. Location presence may be required at acute clinical care facilities. Department Description:

Serving the community since 1961, WakeMed Health & Hospitals is the leading provider of health services in Wake County. With a mission to improve the health and well-being of our community, we are committed to providing outstanding and compassionate care. For more information, visit www.wakemed.org.

EOE

Licensure: Registered Nurse Required Education: Diploma Nursing Required - Or Associate's Degree Nursing Required Bachelor's Degree Nursing Preferred Experience:

5 Years Nursing Required. ideal candidate will have ED and/or Neuro/Stroke experience.

Salary.com Estimation for Quality Documentation Specialist, RN in Raleigh, NC
$72,539 to $89,891
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