Clinical Documentation Improvement Nurse Coder (Certified)

Martin's Point Health Care • Portland, ME

10d

About The Position

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.

Requirements

• Associate’s degree in nursing required
• Current, unrestricted Registered Nurse license required
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required
• 3+ years of clinical nursing experience required
• 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
• 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
• 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

Nice To Haves

• Bachelor’s degree in nursing preferred
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) preferred
• Experience in clinical documentation improvement, risk adjustment, or coding preferred
• Experience in primary care, ambulatory care, or population health preferred

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree