Quality Documentation Specialist, RN

Responsible for concurrent and retrospective review of medical record documentation to collect quality data elements as specified by the CMS/TJC specifications manual or registry manual. Communicates with coding, CDI, physicians and physician extenders or nurses regarding missing, incomplete, unspecific, unclear, or conflicting documentation or impending opportunities within measured time frames. Enters findings into vendor database for hospital measures.

Gathers, analyzes and shares information pertinent to documentation findings and outcomes. Provides subject matter expertise and outreach regarding measure set/registry metrics for designated population. Skills in Excel, Power Point and data visualization technology, such as Tableau, are essential.

Onsite presence is an expectation as determined by manager. Location presence may be required at acute clinical care facilities. The ideal candidate is a Registered Nurse with a strong background in cardiovascular care who combines clinical expertise with a passion for data quality, outcomes measurement, and performance improvement.

This individual will be responsible for abstracting, validating, and reporting data for the Left Atrial Appendage Occlusion (LAAO/Watchman) and Transcatheter Valve Therapy (TVT) registries, ensuring accurate and timely data submission that supports regulatory compliance, quality improvement initiatives, and cardiovascular program excellence. Leveraging their clinical insight and analytical mindset, the successful candidate can follow the patient journey from pre-procedure evaluation through post-procedure follow-up, translating complex clinical events into high-quality registry data that drives improved patient outcomes, supports program performance, and advances excellence in structural heart care.

Department DescriptionServing the community since 1961, WakeMed Health & Hospitals is the leading provider of health services in Wake County. With a mission to improve the health and well-being of our community, we are committed to providing outstanding and compassionate care. For more information, visit www.wakemed.org.

EOE LicensureRegistered Nurse Required EducationDiploma Nursing Required - Or Associate's Degree Nursing Required Bachelor's Degree Nursing Preferred Experience5 Years Nursing Required