Registered Nurse (RN) - Clinical Documentation Specialist, 40 hours/week
MaineGeneral Health•Augusta, ME
•Onsite
About The Position
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. This is an on-site position; remote work is not available.
Requirements
- Maine state licensure as a Registered Nurse (RN)
- Excellent customer service skills
- Proficiency in a suite of Microsoft Office applications
- Medical terminology required
- Ability to work collaboratively with Providers
Nice To Haves
- Certified Clinical Documentation Specialist (CCDS) through the Association for Clinical Documentation Improvement Specialists (ACDIS)
- Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA)
- Billing/coding experience helpful
Responsibilities
- 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.
Benefits
- Health, dental, vision, and wellness programs
- Earned time off
- Paid parental leave
- 403(b) retirement plan with up to 4% company match
- Professional development and advancement opportunities
- Student Loan Assistance
- Employee Assistance Program
- Access wages already earned before payday with Payactiv
- Tuition Reimbursement
- 401(a) retirement income plan
- Short-term and long-term disability insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
