RN CDI Specialist: Elevate Documentation & Quality

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

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.