Clinical Documentation Specialist RN

Clinical Documentation Improvement (CDI) Nurse CoderJoin Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.Position Summary Hybrid in Maine $1,500 sign-on bonus!PRIMARY DUTIES AND RESPONSIBILITIESReviews patient medical records to ensure clinical documentation accurately reflects the patient's conditions, severity of illness, and services provided.Collaborates with providers and care teams to clarify documentation and ensure accurate capture of diagnoses and conditions in accordance with coding and regulatory guidelines.Applies clinical knowledge and coding expertise to support accurate risk adjustment documentation, including identification and validation of HCC conditions.Performs concurrent and retrospective documentation reviews to identify opportunities for documentation improvement and coding accuracy.Ensures documentation supports accurate CPT, ICD-10, and HCC coding and aligns with regulatory and organizational compliance requirements.Communicates documentation clarification opportunities to providers through appropriate query processes that align with industry standards.Educates providers and clinical staff on documentation best practices, coding concepts, and the impact of documentation on quality reporting and risk adjustment.Supports clinical quality initiatives by identifying documentation gaps that impact quality measures and patient outcomes.Maintains accurate records of reviews, queries, and outcomes within designated tracking systems.Collaborates with coding, quality, and clinical leadership to improve documentation workflows and reporting accuracy.POSITION QUALIFICATIONSEducation:Associate's degree in nursing requiredBachelor's degree in nursing preferredLicensure/certification:Current, unrestricted Registered Nurse license requiredCertified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required. CDI, CRC, CPMA, COC, CEMCCertified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) preferredExperience:3+ years of clinical nursing experience required.Experience in clinical documentation improvement, risk adjustment, or coding preferred.Experience in primary care, ambulatory care, or population health preferred.Knowledge:Knowledge of medical terminology, disease processes, and clinical documentation standardsKnowledge of ICD-10, CPT, and HCC coding methodologiesKnowledge of risk adjustment principles and quality reporting requirementsSkills:Strong analytical and critical thinking skillsExcellent written and verbal communication skillsAbility to review and interpret complex clinical documentationStrong organizational and attention-to-detail skillsProficiency with electronic medical records and clinical documentation systemsAbilities:Ability to collaborate effectively with providers and interdisciplinary teamsAbility to maintain confidentiality and comply with regulatory requirementsAbility to manage multiple priorities and meet deadlinesAbility to interpret and apply coding and documentation guidelinesPay Range: $86,926.10 - $107,379.30This position is not eligible for immigration sponsorship.We are an equal opportunity/affirmative action employer.Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact View email address on click.appcast.io you have a question about careers at Martin's Point Health Care? Contact us at: View email address on click.appcast.io