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Documentation Specialist Rn Jobs in Raleigh, NC (NOW HIRING)

Magicforce

CDI Specialist

Raleigh, NC

$40 - $60/hr

... Documentation Specialist Qualifications * Must have at least one of the following: * License to practice as a Registered Nurse preferred (any state) * Credentialed as a RHIA (Registered Health ...

Lifepoint Health

Assessment Specialist, RN

Raleigh, NC · On-site

Assessment Specialist, RN Schedule: Full-time, 7a-7:30p Your experience matters Triangle Springs is ... Conducts initial evaluation, initiates the assessment, documents patient symptomology, functioning ...

WakeMed

OR Education Specialist (RN)

Raleigh, NC · On-site

Overview The OR Education Resource Specialist, RN assesses, plans, implements, and evaluates continuing educational needs of nursing staff and inpatients. Proctors and mentors nurses enrolled in ...

Star Nursing

RN Registered Nurse

Butner, NC · On-site

$58/hr

Registered Nurse (RN) Job Details: * Location: Butner, NC 27509 * Facility : Correctional * Shifts ... Communicate with collaborating physicians or specialists regarding patient care * Educate patients ...

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How much do documentation specialist rn jobs pay per hour?

As of Jul 27, 2026, the average hourly pay for documentation specialist rn in Raleigh, NC is $23.55, according to ZipRecruiter salary data. Most workers in this role earn between $17.74 and $26.63 per hour, depending on experience, location, and employer.
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Clinical Documentation Specialist position

Magicforce

Raleigh, NC

$40 - $60/hr

Contractor

Posted 9 days ago

Job description

Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.

  • Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients
  • Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis
  • Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities
  • Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses - obtaining missing information via a query when necessary

Clinical Documentation Specialist Qualifications

  • Must have at least one of the following:
    • License to practice as a Registered Nurse preferred (any state)
    • Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)
  • Must have all of the following:
    • 1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience
    • CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required

Additional notes:

Candidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience. We are looking for someone who has had experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records