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

Datavant

CDQI Nurse Specialist- PRN

Raleigh, NC · On-site

$40 - $45/hr

As a Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role in ... Registered Nurse license, Bachelor's degree in Nursing * CCDS or CDIP certification required * Must ...

Datavant

CDQI Nurse Specialist- FT

Raleigh, NC

$40 - $45/hr

As a Clinical Documentation Quality Improvement (CDQI) Specialist, you will play a pivotal role in ... Registered Nurse license, Bachelor's degree in Nursing * CCDS or CDIP certification required * Must ...

Star Nursing

RN Registered Nurse

Butner, NC

$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 Jun 15, 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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Documentation Specialist Rn jobs near you

Clinical Documentation Specialist

Magicforce

Raleigh, NC

$40 - $60/hr

Contractor

Posted 3 days ago

Job description

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 to validate the accuracy of patient medical record documentation obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided.


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