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

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

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

Clinical Documentation Specialist

We’re seeking a detail-oriented and collaborative Clinical Documentation Special...

Location

United States , Concord

Salary:

49.00 - 56.00 USD / Hour

Emerson Hospital

Expiration Date

Until further notice

Requirements

Bachelor of Science in Nursing (BSN) or Bachelor of Science in Biology or a related healthcare clinical program (e.g., Medical Records/Health Information Management)
3–5 years of acute care or equivalent clinical experience, or 3+ years of inpatient coding experience
Current Massachusetts Registered Nurse (RN) license and/or AHIMA coding certification (e.g., CCS, RHIT, RHIA) required
Ability to work independently and manage responsibilities with minimal supervision
Strong verbal and written communication skills
Proven ability to build effective working relationships with a wide range of healthcare providers
Team-oriented mindset with strong collaboration and information-sharing skills
Critical thinking and problem-solving abilities in complex clinical scenarios
Strong organizational skills with the ability to stay focused despite frequent interruptions
Proficiency with computer systems and ability to quickly learn new software applications

Job Responsibility

Review medical records to ensure accurate, complete, and compliant clinical documentation
Collaborate with physicians and care teams to clarify and improve documentation quality
Apply clinical and coding knowledge to support accurate code assignment and reimbursement
Facilitate documentation improvement initiatives in both concurrent and retrospective reviews
Educate providers and care teams on CMS regulations, documentation standards, and best practices
Partner with coding professionals to ensure alignment between documentation and coding outcomes
Support quality, compliance, and continuous improvement initiatives across the organization

What we offer

Competitive compensation and comprehensive benefits

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

New

Rn Trauma Program Specialist

In collaboration with the trauma program manager, the RN Trauma Program Speciali...

Location

United States , Colorado Springs

Salary:

40.77 - 73.12 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

3 years recent hospital experience
1 year in a critical care area (ICU or Emergency Department)
Basic computer skills
Associates Nursing Degree Required: Graduate of an accredited School of Nursing
Current CO RN license
BLS required from AHA
TNCC required upon hire or within one year of hire/transfer
Membership to a related professional organization preferred (Society of Trauma Nurses, Emergency Nurses Association, American Association of Critical Care Nurses), preferred
BSN preferred

Job Responsibility

Collaborates with the trauma program manager to develop and execute performance improvement processes that support optimal outcomes for trauma patients
Performs concurrent process improvement and evaluation of trauma care throughout the continuum, from pre-hospital, emergency room, operative, inpatient and discharge
Assesses compliance with trauma protocols and guidelines by observation and chart review
Reviews trauma team activations and assesses for appropriateness based on established criteria
Tracks findings within the trauma process improvement program and documents loop closure of any findings
Participates in multidisciplinary patient rounds as part of concurrent review process
Monitors patient progress through the continuum of care for ongoing identification of potential care issues and facilitates timely resolution through communication and collaboration with the care team
Actively participates in quality improvement initiatives and projects
Collaborates with hospital department leaders and key stakeholders to facilitate trauma program processes
Assists with preparation for State and ACS trauma designation and verification reviews

What we offer

medical
prescription drug
dental
vision plans
life insurance
paid time off (full-time benefit eligible employees may receive a minimum of 14 paid time off days, including holidays annually)
tuition reimbursement
retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings
health/dental/vision
FSA

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

Quality Specialist LPN/RN

Quality Specialist – Blue Ridge Care Your expertise helps ensure excellence, co...

Location

United States , Winchester

Salary:

29.00 - 36.50 USD / Hour

Blue Ridge Hospice

Expiration Date

Until further notice

Requirements

Current, unrestricted RN or LPN license in Virginia or compact multistate license eligible to practice in Virginia
Minimum of three (3) years of clinical nursing experience in hospice or palliative care
Strong knowledge of hospice principles, including pain and symptom management and end-of-life care
Familiarity with state and federal hospice regulations
Proficiency in EMR systems and documentation standards
Excellent verbal and written communication skills
Strong organizational, time-management, and critical-thinking skills
Valid driver's license and insured automobile
ability to travel throughout the service area

Job Responsibility

Conduct medical record chart reviews and focused compliance audits
provide written feedback to staff regarding deficiencies and required corrections
Analyze documentation trends and report high-risk or unfavorable findings to leadership to support education and performance improvement
Maintain up-to-date knowledge of federal, state, and accreditation standards and educate staff to ensure compliance
Attend Interdisciplinary Team (IDT) meetings to ensure regulatory and accreditation compliance
Participate in departmental and organizational quality assessment and improvement initiatives
Support management of the Hospice Outcomes and Patient Evaluation (HOPE) Tool, ensuring complete and accurate datasets prior to submission
Educate staff on HOPE requirements and proper EMR documentation
Ensure medical records are accurate, complete, secure, and HIPAA-compliant
Assist with scanning, indexing, discharge paperwork, letters, appeals, and medical record requests

What we offer

Competitive Pay
PTO & Paid Volunteer Time
Comprehensive Health Benefits
Tuition Reimbursement & Scholarships
Peer Support & Mentorship
30% Thrift Shop Discount
Career Growth

Fulltime

Select Country

RN Documentation Improvement Specialist

Advocate Health Care

Location:
United States , Kings Mountain

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 13, 2026

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

Similar Jobs for RN Documentation Improvement Specialist

Clinical Documentation Specialist RN

RN Documentation Improvement Specialist

Clinical Documentation Specialist-RN

Clinical Documentation Specialist

Quality Management Nurse Specialist RN II

Rn Trauma Program Specialist

Clinical Nurse Specialist

Quality Specialist LPN/RN

Our AI answers in your language

RN Documentation Improvement Specialist

Advocate Health Care

Location:United States , Kings Mountain

Category:Nursing

Contract Type:Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:February 13, 2026

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

Similar Jobs for RN Documentation Improvement Specialist

Clinical Documentation Specialist RN

RN Documentation Improvement Specialist

Clinical Documentation Specialist-RN

Clinical Documentation Specialist

Quality Management Nurse Specialist RN II

Rn Trauma Program Specialist

Clinical Nurse Specialist

Quality Specialist LPN/RN

Location:
United States , Kings Mountain

Category:
Nursing

Contract Type:
Not provided

Job Posted:
February 13, 2026