Documentation Specialist

Harboroaks; Wilmington (NC); On-site; USD 42,000 - 64,000; Full time

Job summary

Harboroaks seeks a detail‑oriented professional to review discharged patient records, perform data abstraction and analysis, and provide data‑driven insights to support performance improvement initiatives.

The role collaborates with clinical teams on patient safety and quality of care, participates in risk management, and helps implement quality improvement plans while upholding professional and empathetic customer service.

Qualifications

• Review discharged patient records daily for completeness and regulatory standards.
• Perform data abstraction and analysis to meet payer and regulatory requirements.
• Collaborate with clinical teams on patient safety and quality of care.
• Participate in risk management and quality improvement initiatives.
• Demonstrate a positive, empathetic and professional attitude toward customers, resolving complaints when needed.

Responsibilities

• Review discharged patient records daily for completeness and regulatory standards.
• Perform data abstraction and analysis for payers and regulatory bodies.
• Collect and present data to drive facility performance improvement initiatives.
• Attend performance improvement meetings and support routine regulatory goals.
• Assist the department director with routine assignments.
• Collaborate with clinical teams on patient safety and quality of care.
• Participate in risk management and quality improvement initiatives.
• Develop and support implementation of quality improvement plans.

Skills

Data abstraction

Data analysis

Regulatory compliance

Quality improvement

Clinical collaboration

Education

High school diploma or equivalent

Bachelor's degree in health services

Job description

Overview

PURPOSE STATEMENT:Ensure compliance by supporting the patient’s perspective and ensure patient rights are protected.

Responsibilities

• Review all discharged patient records daily for completeness and to meet regulatory standards
• Perform data abstraction and analysis to meet specific requirements by various payers and regulatorybodies
• Collect and present data in a useful format to drive facility performance improvement initiatives
• Attend performance improvement meetings, participate in projects and provide support in meetingroutine regulatory goals
• Assist the department director in routine departmental assignments and assigned tasks
• Collaborate with clinical teams on patient safety and quality of care issues
• Participate in risk management process and quality of care initiatives
• Participate in development quality improvement plans and goals for the facility, and supportimplementation process to achieve performance goals
• Demonstrate a positive, empathetic and professional attitude towards customers always. Whenpatient needs are not met, acknowledge and work to resolve complaints. Recognize that patient safetyis a top priority

OTHER FUNCTIONS: Perform other functions and tasks as assigned.

Qualifications

• High school diploma or equivalent required
• Bachelor's degree in health services preferred

We are committed toprovidingequalemploymentopportunitiestoall applicantsforemploymentregardlessofanindividual’scharacteristicsprotected byapplicable state,federalandlocallaws.