Top 25 Documentation improvement nurse coder (certified) Jobs in Westbrook, Me

Clinical Documentation Improvement Nurse Coder (Certified)
Martin's Point Health Care —Portland, ME
- Full-time
- Nursing
- RN License
- Writing skills
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2d
RN/LPN Charge Nurse 1st Shift (Mon-Fri)
PIPER SHORES —Scarborough, ME
- $35.00 - $47.25 an hour
- Monday to Friday
- CPR Certification
- Skilled nursing facility
- Current TB test
- Paid holidays
- Disability insurance
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2d
Weekend Supervisor - RN
Gorham House —Gorham, ME
- $47 - $51 an hour
- Weekends as needed
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Dental insurance
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Registered Nurse - Skilled Nursing
Gorham House —Gorham, ME
- Full-time
- CPR Certification
- Nursing
- Skilled nursing facility
- Disability insurance
- Dental insurance
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Inpatient Coder III
MaineHealth —Scarborough, ME
- $29.45 - $39.84 an hour
- Email
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Parental leave
Registered Nurse Centralized Services - Remote after onsite training in Portland
Martin's Point Health Care —Portland, ME
- Full-time
- Nursing
- Vital signs
- RN License
2d
Wellness Director
The Enclave Of Scarborough —Scarborough, ME
- Online Application
- CPR Certification
- Nursing
- RN License
- Health insurance
- Tuition reimbursement
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Care Manager RN - Per Diem
Optum —Portland, ME
- $28.27 - $50.48 an hour
- Full-time
- Nursing
- RN License
- Hospital
- Flexible schedule
Agency Nurse
NORTHEAST RESIDENTIAL SERVICES LLC —Gray, ME
- $85,000 - $90,000 a year
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
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Registered Nurse
CFG HEALTH SYSTEM LLC —Portland, ME
- Part-time
- CPR Certification
- Nursing
- RN License
Quick Apply
Registered Nurse - 32hrs per week
Martin's Point Health Care —Portland, ME
- $34 - $45 an hour
- Full-time
- Nursing
- RN License
- BLS Certification
Quick Apply
Updated HH/HOS Nurse Job Post Questions_Q12026
BAYADA Home Health Care —Portland, ME
- $64 - $70 per point
- Nursing
- Patient monitoring
- RN License
- Paid training
- Mileage reimbursement
Quick Apply
Hospice Registered Nurse per diem
Affinity Hospice Management LLC —South Portland, ME
- Per diem
- CPR Certification
- Nursing
- RN License
Quick Apply
Hospice Registered Nurse
Prime Source —Portland, ME
- Full-time
- CPR Certification
- Nursing
- RN License
- Health insurance
- Dental insurance
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Nurse Manager - Long Term Care
Seaside Rehabilitation —Portland, ME
- $41.50 - $48.50 an hour
- Full-time
- CPR Certification
- Nursing
- Skilled nursing facility
- Disability insurance
- Health insurance
Quick Apply
Hospice Registered Nurse Case Manager RN
Affinity Hospice Management LLC —South Portland, ME
- Full-time
- CPR Certification
- Nursing
- RN License
Quick Apply
CRNA (Certified Nurse Anesthetist) Full Time
Spectrum Healthcare Partners —Portland, ME
- Full-time
- Nursing
- Surgery
- RN License
- Profit sharing
- Health savings account
Quick Apply
Licensed Practical Nurse (LPN)
ConvenientMD —Saco, ME
- Part-time
- BLS Certification
- Urgent Care
- HIPAA
- Disability insurance
- Health insurance
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Licensed Practical Nurse (LPN) - Urgent Care
ConvenientMD —Portland, ME
- Part-time
- BLS Certification
- Urgent Care
- HIPAA
- Disability insurance
- Health insurance
Quick Apply
Clinical Donation Coordinator I - PeeDee Region
WE ARE SHARING HOPE SC —United States
- On call
- Mid-level
- Operating room
- 2 years

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documentation improvement nurse coder (certified) jobs near westbrook, me

Clinical Documentation Improvement Nurse Coder (Certified)

Martin's Point Health Care -
Portland, ME

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Job Details

Full-time
2 days ago

Qualifications

RN License
Associate's degree
Associate Degree in Nursing

Full Job Description

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

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.

Job Description

PRIMARY DUTIES AND 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.

POSITION QUALIFICATIONS

Education:

Associate’s degree in nursing required
Bachelor’s degree in nursing preferred

Licensure/certification:

Current, unrestricted Registered Nurse license required
Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) preferred

Experience:

3+ years of clinical nursing experience required.
Experience in clinical documentation improvement, risk adjustment, or coding preferred.
Experience in primary care, ambulatory care, or population health preferred.

Knowledge:

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

Skills:

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

Abilities:

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

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [email protected]

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]

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Refine Your Search

documentation improvement nurse coder (certified) jobs in westbrook, me

Clinical Documentation Improvement Nurse Coder (Certified)

RN/LPN Charge Nurse 1st Shift (Mon-Fri)

Weekend Supervisor - RN

Registered Nurse - Skilled Nursing

Inpatient Coder III

Registered Nurse Centralized Services - Remote after onsite training in Portland

Wellness Director

Care Manager RN - Per Diem

Agency Nurse

Registered Nurse

Registered Nurse - 32hrs per week

Updated HH/HOS Nurse Job Post Questions_Q12026

Hospice Registered Nurse per diem

Hospice Registered Nurse

Nurse Manager - Long Term Care

Hospice Registered Nurse Case Manager RN

CRNA (Certified Nurse Anesthetist) Full Time

Licensed Practical Nurse (LPN)

Licensed Practical Nurse (LPN) - Urgent Care

Clinical Donation Coordinator I - PeeDee Region

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