RN Documentation Improvement Specialist Job at Advocate Health Care (Kings Mountain)

New

Clinical Documentation Specialist RN

Improves the overall quality and completeness of clinical documentation by perfo...

Location

United States

Salary:

38.20 - 57.30 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

Graduate from an accredited school of nursing
BSN
5 years relevant clinical experience
Current nursing license in the State of Illinois
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills
Effective problem-solver with good interpersonal communication skills, verbal and written

Job Responsibility

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements
Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart
Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate
Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
Gather and analyze information pertinent to documentation findings and outcomes
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

RN Documentation Improvement Specialist

RN Documentation Improvement Specialist position at Atrium Health Kings Mountain...

Location

United States , Kings Mountain

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Registered Nurse applicable state Licensure required
Bachelor's Degree Required
Appropriate professional certification required within 3 years of hire date per department protocol
5 years of related nursing experience preferred
Clinical experience within the assigned population
Extensive knowledge of disease processes and clinical outcomes
Case Management experience or background helpful
Strong financial and analytical skills preferred
Word, Outlook, Excel experience preferred

Job Responsibility

Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses
Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review
Demonstrates knowledge and understanding of severity based DRG systems
All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG)
Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews
Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner
Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals
Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary
Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record
Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Clinical Documentation Specialist-RN

This role will facilitate the modifications of clinical documentation through ex...

Location

United States , Chicago

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Graduate from an accredited school of nursing
BSN
5 years relevant clinical experience (For associates in process level 25013 5 years relevant pediatric clinical experience)
Clinical documentation improvement experience preferred
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills
Effective problem~solver with good interpersonal communication skills verbal and written

Job Responsibility

Facilitate the modifications of clinical documentation through extensive initial and concurrent interaction with physicians and other members of the healthcare team to support appropriate documentation of the clinical severity and risk of mortality is captured for the level of services rendered to select inpatients populations
Supports timely accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes and provides education to all members of the health care team on an ongoing basis
Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards evidenced based practice and current regulatory requirements
Educates all internal customers on clinical documentation opportunities

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Quality Management Nurse Specialist RN II

The Quality Management Nurse Specialist RN II is responsible for overseeing the ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of clinical experience as an RN in an acute hospital setting
Must have excellent written and verbal communication and presentation skills
Ability to manage projects independently and assume responsibility for successful completion
Ability to develop and maintain strong working relationships with internal and external clients/ customers /members
Must have excellent analytical skills, working knowledge of statistics and reporting
Must be detail-oriented and effective critical thinking skills
Proficient in Microsoft Office (Word, Excel)
Strong interpersonal skills and high level of professionalism
Ability to work independently and within a team environment

Job Responsibility

Overseeing the clinical aspects for quality improvement projects/activities
Ensuring program activities are completed in a high quality and timely manner and ensuring compliance with all regulatory guidelines
Leads and/or participates in multi-department/cross-functional committees and work groups which support key initiatives, prepares reports, data, agendas/minutes or other materials for committee presentation and management
Develops and implements project-related communication including, but not limited to, member/physician mailings, IVR scripts, emails, business plans, graphics, and maintains minutes and agendas
Develops and/or maintains relationships with other external organizations to expand key partnerships
Creates, maintains and implements training/education and supporting documentation for internal and external clients/customers/members
Develops and submits regulatory reports at the time and in the manner required by state or federal agencies such as Centers for Medicare and Medicaid Services(CMS)
Conducts/ performs clinical review of assigned potential quality issue cases (PQI), and close cases within regulatory timeframe, and presents appropriate cases to the peer review committee for action and resolution
Perform other duties as assigned

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Clinical Nurse Specialist

Location

United States

Salary:

51.05 - 76.60 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Masters of Nursing Degree as APRN-CNS
2 years RN experience preferred
1 year APRN-CNS experience in the relevant setting preferred
Well-developed interpersonal and communication skills
Proficiency with an Electronic Medical Record
National certification as a CNS from an accredited body
Current Illinois APRN License
Current Illinois Registered Nurse license
Current Illinois Controlled Substance License within 6 months of hire
Eligible for DEA registration

Job Responsibility

Completes and documents accurate comprehensive, episodic history and physical assessments
Performs ordering, conducting, supervising, and interpreting diagnostic laboratory and imaging studies
Prescribes treatments, and therapies not limited to medications, diet, supplies, prosthetic devices, and equipment
Implements primary and secondary prevention strategies and management of acute and chronic health problems
Provides clear, concise, accurate, and legible information regarding patient care in the record
Formulates a comprehensive plan of care in collaborating with the patient and interdisciplinary team
Fulfills billing and productivity metrics requirements where appropriate and maintains relevant documentation
Provides other clinical duties as appropriate
Works with interdisciplinary team to develop resource conscious care delivery strategies
Provides education to patients, families, staff and significant others using established education materials and assists patient and families in making healthcare decisions

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Opportunity for annual increases based on performance
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions

Fulltime

New

Clinical Informatics Specialist RN

The Clinical Informatics Specialist RN is a clinical professional who is under t...

Location

United States , Augusta

Salary:

Not provided

Wellstar Health System

Expiration Date

Until further notice

Requirements

Associates and/or equivalent Required
Bachelors of Science in a Health related field - Preferred
Reg Nurse (Single State) or RN - Multi-state Compact
Basic Life Support or BLS - Instructor
Minimum 3 years of experience in clinical practice at the bedside and/or information systems related activities Required
experience with a combination of clinical practice and information system implementations. Preferred
Ability to read, write and speak the English language.
Strong customer service skills.
Proficient in the use of Internet browsers and Microsoft Office products.
Excellent verbal and written communication skills.

Job Responsibility

Provide clinical informatics services to individuals, physicians, departments and agencies that are a part of WellStar Health System.
Participates in the assessment of needs pertaining to clinical information systems, including hardware, software, staff development and management support.
Provides content expertise that supports care area teams.
In collaboration with clinical leaders, this role is responsible for the design, development and implementation of the clinical informatics plan.
Provides leadership and change management methodologies to advance the clinical team utilization of informatics.
Oversees end user optimization and efficiency, embeds evidence based, and analytics model to ensure patient outcomes and improve clinical performance.
Works with members of the information technology departments, providers, super-users, clinical departments and other WHS personnel to accomplish strategic goals.
Analyze clinical workflows and be able to promote process changes to support the proficient use of the system.
Assess information and knowledge needs of health care professionals and patients.
Characterize, evaluate, and refine clinical processes.

Fulltime

New

Clinical Nurse Specialist Cardiac and Heart Failure

Location

United States

Salary:

51.05 - 76.60 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Masters of Nursing Degree as APRN-CNS or must be currently enrolled
2 years RN experience preferred
1 year APRN-CNS experience in the relevant setting preferred
Well-developed interpersonal and communication skills
Proficiency with an Electronic Medical Record
National certification as a CNS from an accredited body
Current Illinois APRN License
Current Illinois Registered Nurse license
Current Illinois Controlled Substance License within 6 months of hire
Eligible for DEA registration

Job Responsibility

Completes and documents accurate comprehensive, episodic history and physical assessments
Performs ordering, conducting, supervising, and interpreting diagnostic laboratory and imaging studies
Prescribes treatments, and therapies not limited to medications, diet, supplies, prosthetic devices, and equipment
Implements primary and secondary prevention strategies and management of acute and chronic health problems
Provides clear, concise, accurate, and legible information regarding patient care in the record
Formulates a comprehensive plan of care in collaborating with the patient and interdisciplinary team
Fulfills billing and productivity metrics requirements where appropriate and maintains relevant documentation
Provides other clinical duties as appropriate
Works with interdisciplinary team to develop resource conscious care delivery strategies
Provides education to patients, families, staff and significant others using established education materials and assists patient and families in making healthcare decisions

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Clinical Nurse Specialist Cardiac and Heart Failure

Location

United States

Salary:

51.05 - 76.60 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Masters of Nursing Degree as APRN-CNS or must be currently enrolled
2 years RN experience preferred
1 year APRN-CNS experience in the relevant setting preferred
Well-developed interpersonal and communication skills
Proficiency with an Electronic Medical Record
National certification as a CNS from an accredited body
Current Illinois APRN License
Current Illinois Registered Nurse license
Current Illinois Controlled Substance License within 6 months of hire
Eligible for DEA registration

Job Responsibility

Completes and documents accurate comprehensive, episodic history and physical assessments
Performs ordering, conducting, supervising, and interpreting diagnostic laboratory and imaging studies
Prescribes treatments, and therapies not limited to medications, diet, supplies, prosthetic devices, and equipment
Implements primary and secondary prevention strategies and management of acute and chronic health problems
Provides clear, concise, accurate, and legible information regarding patient care in the record
Formulates a comprehensive plan of care in collaborating with the patient and interdisciplinary team
Fulfills billing and productivity metrics requirements where appropriate and maintains relevant documentation
Provides other clinical duties as appropriate
Works with interdisciplinary team to develop resource conscious care delivery strategies
Provides education to patients, families, staff and significant others using established education materials and assists patient and families in making healthcare decisions

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

RN Documentation Improvement Specialist

Advocate Health Care

Location:
United States , Kings Mountain

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 20, 2026

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Clinical Nurse Specialist Cardiac and Heart Failure

RN Documentation Improvement Specialist

Advocate Health Care

Location:United States , Kings Mountain

Category:Nursing

Contract Type:Not provided

Salary:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:February 20, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

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Location:
United States , Kings Mountain

Category:
Nursing

Contract Type:
Not provided

Job Posted:
February 20, 2026