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Clin Documentation Spec, RN ,Home Health (full-time)

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Job ID 32067 Job Category Clinical Professional Shift Day Employment Type Full-Time Campus WakeMed Business Center (Highwoods Building) Department Administration

Serving the community since 1961, WakeMed Health & Hospitals is a nationally recognized, private, not-for-profit health care organization founded and based in Raleigh, N.C. The largest health system in Wake County, WakeMed exists to improve the health and well-being of our community by providing outstanding, compassionate, patient- and family-centered care to all. The 919-bed system comprises a network of facilities throughout the Triangle area, delivering health and wellness services that bring added value to the communities we serve. WakeMed is a leader in cardiac and vascular care, women’s and children’s services, emergency medicine and trauma care, physical rehabilitation, orthopaedics and neurosciences. Specialty facilities include the WakeMed Heart Center, Children’s Hospital, Women’s Pavilion and Birthplace, Rehabilitation Hospital, Adult and Children’s Emergency Departments and a Level 1 Trauma Center. WakeMed’s team of more than 9,400 employees, 2,000 volunteers, 1,300 affiliated physicians, and the more than 300 physicians employed by WakeMed Physician Practices use the most advanced technologies along with the best minds and the biggest hearts to ensure the finest quality in health care and community health. For more information, visit

As an Equal Opportunity Employer, WakeMed provides an inclusive work environment that
promotes the valuing of differences, respect for people and cooperativeness among our diverse
workforce. WakeMed does not discriminate against any employee or applicant in any terms or
conditions of employment. All applicants/employees are considered for employment, transfer,
promotion or training without regard to race, religion, color, gender, gender identity/expression,
genetics, sexual orientation, age, pregnancy, national origin, disability or veteran status.

The Clinical Documentation Specialist, RN is responsible for concurrent auditing of medical record documentation to ensure documentation adequately reflect care provided, use of resources, and meets regulatory requirements. Works to ensure that documentation is complete and accurately coded. Maintains documentation regarding results of audit activity, educates others in audit review and OASIS requirements, and informs management as necessary. Responsible for leading Performance Improvement initiatives as it relates to any department identified OASIS related documentation. This position understands the needs of the organization and supports the mission, values, and management of patient care services. The Home Health Department provides full service home health to patients in Wake County and some of the surrounding counties.

4 Years Nursing - Related Area Required - And 2 Years Clinical - Home or Community Health Preferred

Graduate Nursing Required - And Master's Degree Nursing Preferred

Registered Nurse Required - And Home Care Coding Specialist - Diagnosis Or Home Care Coding Specialist - OASIS Required - And Certificate OASIS Specialist - Clinical Preferred

: 8-4:30
: As Needed
: as needed

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