Registered Nurse (RN) - Clinical Documentation Specialist, 40 hours/week

MaineGeneral Medical Center; Augusta (ME); On-site; USD 79,000 - 138,000; Full time

Benefits offered by this job

Competitive pay

Comprehensive benefits

403(b) retirement plan

Professional development

Student loan assistance

Job summary

MaineGeneral Health is seeking a Registered Nurse to join as a Clinical Documentation Specialist in Augusta, on-site at the Alfond Center for Health.

This full-time, day-shift role partners with medical staff to ensure accurate documentation and coding support, supporting compliant reimbursement and regulatory standards across the health system.

Join a team committed to quality care and professional growth, with comprehensive benefits and a stable community hospital environment.

Qualifications

• Maine state RN licensure preferred.
• CCDS or CCS preferred.
• Excellent customer service skills.
• Proficiency in Microsoft Office applications.
• Billing/coding experience helpful; medical terminology required.
• Ability to work collaboratively with Providers.

Responsibilities

• Conduct concurrent and retrospective medical record reviews to ensure accurate documentation.
• Identify errors related to coding and documentation.
• Collaborate with coding staff to support accurate coding.
• Collaborate with interdisciplinary teams to assist with reimbursement and performance measures.
• Provide consultation and education to departments to ensure regulatory compliance.

Skills

RN license

CCDS

CCS

Customer service

MS Office

Billing/coding

Medical terminology

Collaboration

Job description

Job Summary: MaineGeneral Health is excited to announce an opportunity for a Registered Nurse to join our team as a Clinical Documentation Specialist! In this role, you will partner closely with medical staff to ensure the accuracy and integrity of patient medical documentation. You will play a key part in the timely capture and recapture of Hierarchical Condition Categories (HCCs) each year, supporting high-quality patient care and regulatory compliance. Please note: This is an on-site position; remote work is not available.

Job Description

Position: RN Clinical Documentation Specialist

Location: Alfond Center for Health, Augusta

Schedule: Full-time (40 hours/week)

Shift: Days

What You'll Do

• Conducts concurrent and retrospective medical record reviews to ensure accurate and specific documentation of diagnoses and procedures.
• Identifies errors and issues related to coding and documentation.
• Collaborates with the coding staff to ensure that the medical record has the necessary documentation to support accurate coding.
• Collaborates with interdisciplinary teams to assist with problem resolution, appropriate reimbursement, and systems/performance measures.
• Provides consultation and education to organizational departments and committees to ensure regulatory compliance and optimum reimbursement.

What You Bring

• Maine state licensure as a Registered Nurse (RN) preferred
• Certified Clinical Documentation Specialist (CCDS) through the Association for Clinical Documentation Improvement Specialists (ACDIS) or Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA) preferred
• Excellent customer service skills
• Proficiency in a suite of Microsoft Office applications
• Billing/coding experience helpful; medical terminology required
• Ability to work collaboratively with Providers

Why Join MaineGeneral?

• Competitive Pay and Comprehensive Benefits: Health, dental, vision, and wellness programs
• Work-Life Balance: Earned time off, paid parental leave, and more
• Financial Security: 403(b) retirement plan with up to 4% company match
• Career Growth: Professional development and advancement opportunities
• Student Loan Assistance: Potential reimbursement to help you thrive
• Compensation Information: $38.00 - $66.50 The hourly pay range shown represents the base pay range for this position. Individual pay is determined based on factors such as experience, qualifications, skills, and market considerations. In addition to base pay, eligible team members may earn additional compensation through shift, weekend, holiday, on-call, and other applicable differentials.
• We are proud to offer a competitive total rewards package designed to recognize our caregivers and support them in delivering exceptional care to the communities we serve.
• Scheduled Weekly Hours: 40
• Job Exempt: No

Benefits

• Supporting all aspects of our employees’ wellness – physical, emotional and financial – is a critical component of being a great place to work. With the wide range of benefits and programs available, employees have the resources they need to be well at every stage of life and plan for the future.
• Physical Wellness: We offer quality health, dental, and vision benefits and wellness programs and resources to provide employees access to resources for a healthy lifestyle and help manage health care costs. Employees have access to industry-leading leave for new parents. A generous earned time plan is offered to all employees- We believe employees need and deserve time away from work to observe holidays, be with family, go on vacation, or simply take care of themselves.
• Emotional Wellness: When life gets challenging, employees have access to our Employee Assistance Program for employees and anyone in their household.
• Financial Wellness: Access the wages you’ve already earned before payday with Payactiv, giving you greater flexibility over your finances. Tuition Reimbursement is available to all employees to further develop skills and career. We offer eligible employees up to 2% of eligible pay in 403(b) company-matching contributions plus another 2% in the 401(a) retirement income plan. Three insurance plans are available to protect your family from the sudden loss of income in the event of your death, terminal illness or serious injury from accident. We offer both short-term and long-term disability insurance to replace a portion of your income if you become disabled and cannot work for a period of time.
• Career Mobility: Helping our employees develop their skills and grow their careers is critical to how we retain our talent and sustain our business. We do this by offering our teammates a variety of leadership-supported programs and learning and development resources for every stage of their professional development. We know that our employees are our most valuable resource – they’re how we grow our business and care for our community.

Equal Opportunity Employer M/F/Vet/Disability

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