Top 14 Clinical documentation specialist Jobs in Portland Me

Clinical Documentation Improvement Nurse Coder (Certified) - Hybrid in Maine
Martin's Point Health Care —Portland, ME
- $86,926.10 - $107,379.30 a year
- Full-time
- Nursing
- RN License
- Writing skills
- Health 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
Clinical Assurance Spec/RN
Northern Light Health —South Portland, ME
- $32.65 - $50.11 an hour
- Full-time
- Nursing
- RN License
- Word processing
3d
Oncology Infusion RN- Per-Diem Westbrook
New England Cancer Specialists —Westbrook, ME
- $45 - $55 an hour
- Per diem
- Private practice
- Nursing
- RN License
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Clinical Support Specialist
Spurwink Services —Portland, ME
- $18 - $22 an hour
- Monday to Friday
- Customer service
- Administrative experience
- High school diploma or GED
- Paid training
- Disability insurance
13d
Registered Nurse
Martin's Point Health Care —Scarborough, ME
- $36.54 - $45.14 an hour
- Full-time
- Nursing
- RN License
- BLS Certification
- Health insurance
- Dental insurance
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3d
Staff RN - ECMO Spec / FT, nights
Children's Nebraska —United States
- Overtime
- Nursing
- RN License
- BLS Certification
- Flexible schedule
Travel IMC RN Job in Birmingham, Alabama
GIFTED Healthcare —United States
- $2,071.19 - $2,122.06 a week
- Overtime
- Nursing
- Medication administration
- RN License
- Health insurance
- Dental insurance
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Travel MedSurg RN Job in Shiprock, New Mexico
GIFTED Healthcare —United States
- $2,845.87 a week
- Overtime
- Nursing
- Patient monitoring
- RN License
- Health insurance
- Dental insurance
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3d

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Registered Nurse - Surgical Services
Central Maine Medical Center —Lewiston, ME
Current and valid state RN License. Supportive leadership, competitive pay, comprehensive benefits, and opportunities for career advancement and specialty…
$37.00 - $51.28 an hour
Baylor Nurse (RN/LPN) – Skilled Nursing & Long-Term Care (SNF) | Weekend Shift
The Cedars —Portland, ME
Current Maine RN or LPN license required. Strong clinical judgment, communication, and documentation skills. Perform resident assessments and monitor changes in…
$32 - $45 an hour
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Medical AR Specialist
Columbus Oncology & Hematology —Dublin, OH
Identify, review, research, and resolve credit balances ensuring the correct disposition of funds. Proven experience in submitting tiered appeals using precise…
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Documentation and Reimbursement Specialist
Nationwide Children's Hospital —Columbus, OH
Five years of experience in related field (physician billing experience), preferred. As required by listed licensure and/or certification requirement.

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Clinical Documentation Improvement Nurse Coder (Certified) - Hybrid in Maine

Martin's Point Health Care -
Portland, ME

Quick Apply

Job Details

Full-time
$86,926.10 - $107,379.30 a year

Benefits

Health insurance
Dental insurance
Paid time off
Vision insurance
Volunteer time off

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

Pay Range: $86,926.10 - $107,379.30 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan. In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.

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

clinical documentation specialist jobs in portland me

Clinical Documentation Improvement Nurse Coder (Certified) - Hybrid in Maine

Inpatient Coder III

Clinical Assurance Spec/RN

Oncology Infusion RN- Per-Diem Westbrook

Clinical Support Specialist

Registered Nurse

Staff RN - ECMO Spec / FT, nights

Travel IMC RN Job in Birmingham, Alabama

Travel MedSurg RN Job in Shiprock, New Mexico

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I want to receive the latest job alert for clinical documentation specialist in portland me

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Position Summary

Job Description

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

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