Documentation Specialist

Duke University Health System is seeking an experienced Documentation Specialist to join our team. The ideal candidate should possess strong attention to detail, excellent organizational skills, and a dedication to providing accurate and comprehensive patient documentation. We are looking for someone who can quickly and effectively capture medical data and ensure it complies with regulations and standards. The Documentation Specialist will need to be able to work independently, as well as collaborate with other departments, while maintaining a high level of professionalism. If you have a Bachelor’s degree in Medical Records or Health Information Management, and have experience in a healthcare setting, we encourage you to apply.

Responsibilities of the Documentation Specialist:

1. Evaluate, record, and interpret patient data to ensure accuracy and compliance with regulations and standards.
2. Provide comprehensive and accurate medical documentation to support patient care and health records.
3. Maintain documentation in electronic and paper health records.
4. Collaborate with other departments to ensure patient data is collected and maintained properly.
5. Monitor and track patient documentation to ensure accuracy and completeness.
6. Create and maintain reports, logs, and other records as needed.
7. Monitor and review healthcare industry regulations and standards to ensure compliance with documentation standards.
8. Identify areas of improvement to enhance the accuracy and efficiency of documentation.
9. Maintain confidentiality of all patient records and information.
10. Assist with audits and other administrative tasks as needed.

According to JobzMall, the average salary range for a Documentation Specialist in Durham, NC, USA is between $37,000 and $63,000 per year. This range is based on salaries reported by employers to Indeed.com, the largest job site in the United States.

Duke Health integrates the Duke University Health System (all of our hospitals and clinics), Duke University School of Medicine, Duke-NUS Medical School, Duke University School of Nursing, Private Diagnostic Clinic (Duke physicians practice), and incorporates the health and health research programs within the Duke Global Health Institute as well as those in schools and centers across Duke University, including the Duke Robert J. Margolis Center for Health Policy.