Clinical Documentation Improvement Coder
Martin's Point Health CareAbout the role
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
Job Profile SummaryThe Clinical Documentation Improvement (CDI) Coder supports accurate clinical documentation and coding practices to ensure complete and compliant capture of diagnoses and services. This role reviews medical records, applies coding guidelines, and collaborates with clinical teams to ensure documentation supports accurate coding, risk adjustment, and quality reporting. The CDI Coder contributes to improved documentation integrity, regulatory compliance, and organizational performance.
Job Description
PRIMARY DUTIES AND RESPONSIBILITIES
Reviews medical records to ensure diagnoses and procedures are documented accurately and coded in accordance with established coding guidelines.
Applies ICD-10-CM, CPT, and HCC coding principles to ensure accurate and compliant documentation and coding practices.
Identifies documentation gaps that may affect coding accuracy, risk adjustment, and quality reporting.
Collaborates with providers and clinical staff to clarify documentation through established query processes.
Supports accurate risk adjustment coding through review and validation of chronic conditions and appropriate documentation.
Ensures coding activities comply with regulatory standards, organizational policies, and coding best practices.
Maintains accurate documentation of coding reviews, queries, and outcomes within applicable systems.
Participates in quality improvement initiatives aimed at improving documentation integrity and coding accuracy.
Assists in educating providers and staff regarding coding and documentation best practices.
Collaborates with CDI, quality, and clinical teams to promote accurate clinical documentation.
Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.
POSITION QUALIFICATIONS
Education:
High School Diploma or equivalent required.
Associate or Bachelor’s degree in Health Information Management or related field preferred.
Licensure/certification:
Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required.
Experience:
2+ years of medical coding experience required.
Experience with risk adjustment coding and HCC documentation preferred.
Experience in ambulatory or primary care coding preferred.
Knowledge:
Knowledge of ICD-10-CM and CPT coding guidelines
Knowledge of risk adjustment models and HCC coding
Knowledge of medical terminology and healthcare documentation standards
Skills:
Strong attention to detail and analytical skills
Strong written and verbal communication skills
Organizational and time management skills
Proficiency with electronic health records and coding systems
Abilities:
Ability to review clinical documentation for accuracy and completeness
Ability to manage multiple coding reviews efficiently
Ability to collaborate effectively with clinical and administrative teams
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