Clinical Documentation Improvement Nurse Coder (Certified)

Martin’s Point Health Care; Portland (ME); On-site; USD 85,000 - 110,000; Full time

Job summary

Martin’s Point Health Care in Maine seeks a Clinical Documentation Improvement (CDI) Nurse Coder to review records, collaborate with providers, and ensure accurate documentation of diagnoses and severity. The role supports risk adjustment, quality reporting, and patient outcomes.

The ideal candidate holds an RN license, 3+ years of clinical nursing experience, and relevant coding certifications or CDI experience.

Qualifications

• RN licensed with an active license.
• 3+ years of clinical nursing experience.
• Experience in CDI or coding preferred.
• Knowledge of ICD-10, CPT, and HCC coding.

Responsibilities

• Reviews patient medical records to ensure documentation reflects conditions and severity.
• Collaborates with providers to clarify documentation and ensure accurate diagnoses.
• Applies coding knowledge for risk adjustment documentation and HCC identification.
• Performs concurrent and retrospective reviews to improve documentation accuracy.
• Ensures CPT, ICD-10, and HCC coding aligns with compliance requirements.
• Communicates documentation clarification opportunities to providers via queries.
• Educates providers and staff on documentation practices and coding impact.
• Supports quality initiatives by identifying documentation gaps related to outcomes.

Skills

Analytical thinking

Communication skills

Documentation review

Interdisciplinary collaboration

Education

Associate's degree in nursing

Bachelor's degree in nursing

Job description

Join 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 amission 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

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 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.

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

POSITION QUALIFICATIONS

Education:

• Associate’s degree in nursing required
• Bachelor’s 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

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

This 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 [e-mail]

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [e-mail]