Clinical Documentation Improvement Coder
Job Location:
Portland, OR - USA
Monthly Salary:
Posted:
Application Deadline:
Vacancies:
Job Summary
Join Martins 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 ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins 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 Martins Point has been certified as a Great Place to Work since 2015.
The Clinical Documentation Improvement (CDI) Coder supports accurate clinical documentation and coding practices to ensure complete and compliant capture of diagnoses and services. This role reviews medical records applies coding guidelines and collaborates with clinical teams to ensure documentation supports accurate coding risk adjustment and quality reporting. The CDI Coder contributes to improved documentation integrity regulatory compliance and organizational performance.
Job Description
PRIMARY DUTIES AND RESPONSIBILITIES
Reviews medical records to ensure diagnoses and procedures are documented accurately and coded in accordance with established coding guidelines.
Applies ICD-10-CM CPT and HCC coding principles to ensure accurate and compliant documentation and coding practices.
Identifies documentation gaps that may affect coding accuracy risk adjustment and quality reporting.
Collaborates with providers and clinical staff to clarify documentation through established query processes.
Supports accurate risk adjustment coding through review and validation of chronic conditions and appropriate documentation.
Ensures coding activities comply with regulatory standards organizational policies and coding best practices.
Maintains accurate documentation of coding reviews queries and outcomes within applicable systems.
Participates in quality improvement initiatives aimed at improving documentation integrity and coding accuracy.
Assists in educating providers and staff regarding coding and documentation best practices.
Collaborates with CDI quality and clinical teams to promote accurate clinical documentation.
Employees are expected to work consistently to demonstrate the mission vision and core values of the organization.
POSITION QUALIFICATIONS
Education:
High School Diploma or equivalent required.
Associate or Bachelors degree in Health Information Management or related field preferred.
Licensure/certification:
Certified Professional Coder (CPC) Certified Coding Specialist (CCS) or equivalent coding certification required.
Experience:
2 years of medical coding experience required.
Experience with risk adjustment coding and HCC documentation preferred.
Experience in ambulatory or primary care coding preferred.
Knowledge:
Knowledge of ICD-10-CM and CPT coding guidelines
Knowledge of risk adjustment models and HCC coding
Knowledge of medical terminology and healthcare documentation standards
Skills:
Strong attention to detail and analytical skills
Strong written and verbal communication skills
Organizational and time management skills
Proficiency with electronic health records and coding systems
Abilities:
Ability to review clinical documentation for accuracy and completeness
Ability to manage multiple coding reviews efficiently
Ability to collaborate effectively with clinical and administrative teams
Do you have a question about careers at Martins Point Health Care Contact us at:
Required Experience:
IC
