RN, Clinical Documentation Improvement Specialist

Prime Healthcare • Lewiston, ME

4d

About The Position

Overview Central Maine Healthcare is seeking a Full Time, RN, Clinical Documentation Improvement Specialist to join our team! Position Summary: The Clinical Documentation Improvement Specialist will facilitate improved quality, accuracy and completeness of medical record documentation and quality gap closure by conducting proactive reviews of patients’ electronic medical records and other data sources. This review will occur in advance of scheduled patient office visits to ensure all gaps in care are identified and addressed by the provider during that visit. In addition, this role may perform audits and medical charts reviews. All duties will be performed in accordance with ICD-10 coding guidelines, internal protocols, and CMS guidance.

Requirements

• Associates’ degree in Nursing or higher required
• Current RN license in good standing required
• Recent clinical experience (minimum 5 years), preferably in primary care setting
• Experience with EMR, preferably Cerner
• Certified Risk Adjustment Coder or Certified Professional Coder through AAPC or CDI or CCS certification through AHIMA, or ability to obtain certification within 6 months from date of hire
• 1+ years recent experience ICD-10 coding with strong attention to detail and high accuracy rate preferred
• 1+ years of recent Risk Adjustment / HCC Coding experience preferred

Nice To Haves

• Bachelor’s Degree in Nursing preferred

Responsibilities

• facilitate improved quality, accuracy and completeness of medical record documentation and quality gap closure
• conducting proactive reviews of patients’ electronic medical records and other data sources
• perform audits and medical charts reviews
• All duties will be performed in accordance with ICD-10 coding guidelines, internal protocols, and CMS guidance.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees