Clinical Documentation Improvement Coder

Martin's Point Health Care•Portland, ME

About The Position

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.

Requirements

High School Diploma or equivalent required.
Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required.
2+ years of medical coding experience required.
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
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
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

Nice To Haves

Associate or Bachelor’s degree in Health Information Management or related field preferred.
Experience with risk adjustment coding and HCC documentation preferred.
Experience in ambulatory or primary care coding preferred.

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.