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Clinical Documentation Specialist

Job Description

Clinical Documentation Specialist

Full Job Description

This is a Hybrid Position-Registered Nurses encouraged to Apply

Position Summary

  • This individual is responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. S/he will obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers and coordinate with Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients. S/he will also assure that the clinical information utilized in profiling and reporting outcomes is complete and accurate. S/he will provide education for all members of the patient care team on documentation guidelines.

Required Minimum Knowledge, Skills, and Abilities (KSAs)

  • Education: BSN or 4-year-degree preferred.
  • License/Certifications: State licensed R.N.
  • Experience: Recent clinical experience (minimum 5 years).
  • Strong organizational and prioritization skills and demonstrated leadership skills.
  • Excellent communication skills adaptable to individual levels of understanding.
  • Highly developed problem solving, deductive reasoning skills.
  • Dependable, self-directed, and respectful.
  • Able to participate collaboratively with all members of care team.
  • Ability to learn/develop the skills necessary to perform the Clinical Documentation Management Program.

Additional Information

MaineHealth was ranked one of America’s Best Large Employers in 2022 by Forbes!

MaineHealth is a not-for-profit integrated health system whose vision is, “Working together so our communities are the healthiest in America.” MaineHealth consists of nine local health systems, a comprehensive behavioral health care network, diagnostic services, home health agencies, and 1,700 employed clinicians working together through the MaineHealth Medical Group. With approximately 22,000 care team members, MaineHealth provides preventive care, diagnosis and treatment to 1.1 million residents in Maine and New Hampshire. Learn more about our system at mainehealth.org

At MaineHealth, we offer benefits that support an individual's needs for today and flexibility to plan for tomorrow. Our packages include health and dental insurances, paid parental leave, retirement program, generous paid time off, and much more! Our comprehensive array of benefits are competitive, affordable, and include choices that meet specific, but ever changing, needs.

With a career at any of the MaineHealth locations, you’ll be working with health care professionals that truly value the people around them – both within the walls of the organization and the neighborhoods that surround it. We are deeply invested in the well-being of our communities and care team members. We believe in fostering a work environment of strong commitment, compassionate caring and continuous improvement. Join us, and your abilities will be challenged and enhanced as you take your career to a new level.

Location: MaineHealth · Integ Fin CBO- Clin Doc Mgt

Schedule: Full Time, Day Shift, 40

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