Clinical Documentation Improvement Nurse Coder (Certified) Hybrid in Maine 1,500 sign-on bonus

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.

Position Summary

The Clinical Documentation Improvement (CDI) Nurse Coder supports accurate and complete clinical documentation that reflects the severity of illness quality of care and services provided to patients. This role reviews medical records collaborates with providers and applies clinical expertise and coding knowledge to ensure documentation integrity and compliance with regulatory and organizational standards. The CDI Nurse Coder promotes accurate diagnosis capture supports quality reporting and contributes to improved patient outcomes and population health management.

Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

• Reviews patient medical records to ensure clinical documentation accurately reflects the patients 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.

Employees are expected to work consistently to demonstrate the mission vision and core values of the organization.

POSITION QUALIFICATIONS

Education:

• Associates degree in nursing required
• Bachelors degree in nursing preferred

Licensure/certification:

• Current unrestricted Registered Nurse license required
• Certified Professional Coder (CPC) Certified Coding Specialist (CCS) or equivalent coding certification required
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) preferred

Experience:

• 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 standards
• Knowledge of ICD-10 CPT and HCC coding methodologies
• Knowledge of risk adjustment principles and quality reporting requirements

Skills:

• Strong analytical and critical thinking skills
• Excellent written and verbal communication skills
• Ability to review and interpret complex clinical documentation
• Strong organizational and attention-to-detail skills
• Proficiency with electronic medical records and clinical documentation systems

Abilities:

• Ability to collaborate effectively with providers and interdisciplinary teams
• Ability to maintain confidentiality and comply with regulatory requirements
• Ability to manage multiple priorities and meet deadlines
• Ability to interpret and apply coding and documentation guidelines

Pay Range: $86926.10 - $107379.30 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience skills qualifications and other job-related considerations. Employees may also be eligible for additional compensation including incentive or commission-based programs where applicable and subject to the terms of the relevant plan. In addition to base compensation we offer a comprehensive benefits package including medical dental vision retirement savings with employer contributions paid time off (including volunteer time off!) pie day and other employee benefits.

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