Job Description

Clinical Documentation Specialist

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.

Position: RN Clinical Documentation Specialist

Location: Alfond Center for Health, Augusta

Schedule: Full-time (40 hours/week)

Shift: Days

What You'll Do:

• 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.

What You Bring:

• Maine state licensure as a Registered Nurse (RN) preferred
• Certified Clinical Documentation Specialist (CCDS) through the Association for Clinical Document Improvement Specialists (ACDIS) or Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA) preferred
• Excellent customer service skills
• Proficiency in a suite of Microsoft Office applications
• Billing/coding experience helpful, medical terminology required
• Ability to work collaboratively with Providers

Why Join MaineGeneral?

• Competitive Pay and Comprehensive Benefits: Health, dental, vision, and wellness programs
• Work-Life Balance: Earned time off, paid parental leave, and more
• Financial Security: 403(b) retirement plan with up to 4% company match
• Career Growth: Professional development and advancement opportunities
• Student Loan Assistance: Potential reimbursement to help you thrive

Scheduled Weekly Hours: 40

Scheduled Work Shift:

Job Exempt: No

Benefits

Supporting all aspects of our employees' wellness physical, emotional and financial is a critical component of being a great place to work. With the wide range of benefits and programs available, employees have the resources they need to be well at every stage of life and plan for the future.

Physical Wellness

• We offer quality health, dental, and vision benefits and wellness programs and resources to provide employees access to resources for a healthy lifestyle and help manage health care costs.
• Employees have access to industry-leading leave for new parents.
• A generous earned time plan is offered to all employees - We believe employees need and deserve time away from work to observe holidays, be with family, go on vacation, or simply take care of themselves.

Emotional Wellness

When life gets challenging, employees have access to our Employee Assistance Program for employees and anyone in their household.

Financial Wellness

• An employee discount program is available to all employees for services provided by MaineGeneral Medical Center.
• Loan Reimbursement is available for this position dependent upon current degree level. Please discuss benefit with the recruiter.
• Tuition Reimbursement is available to all employees to further develop skills and career.
• We offer eligible employees up to 2% of eligible pay in 403(b) company-matching contributions plus another 2% in the 401(a) retirement income plan.
• Three insurance plans are available to protect your family from the sudden loss of income in the event of your death, terminal illness or serious injury from accident.
• We offer both short-term and long-term disability insurance to replace a portion of your income if you become disabled and cannot work for a period of time.

Career Mobility

Helping our employees develop their skills and grow their careers is critical to how we retain our talent and sustain our business. We do this by offering our teammates a variety of leadership-supported programs and learning and development resources for every stage of their professional development. We know that our employees are our most valuable resource they are how we grow our business and care for our community.

Equal Opportunity Employer M/F/Vet/Disability

Assistive technologies are available. Application assistance for those requesting reasonable accommodation to the career site is available by contacting HR at (207) 861-3440.

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