Ambulatory Clinical Documentation Improvement Specialist - Registered Nurse (RN)

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  • South Portland, ME
  • Maine Medical Partners
  • Full Time - Day Shift
  • Professional - Clinical
  • Req #: 136280
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MaineHealth has a unique opportunity for a Registered Nurse to fill the role of Ambulatory Clinical Documentation Improvement Specialist. This is an innovative, new program focusing on ambulatory patients in our MaineHealth Internal Medicine and Family Medicine practices. 

In this important role, the selected RN will review medical records ensuring the documentation accurately reflects the current clinical and social complexity of the patient. This position will also partner with our Coding & Credentialing Teams to educate providers on the documentation required to capture significant health indicators, maintain data integrity and ensure accurate reimbursement.

The RN we are seeking has 5 years’ nursing experience; a BSN is preferred. Prior experience working in a Clinical Document Improvement capacity is preferred.  Prior positions in Case Management and/or in an outpatient setting are ideal.  The willingness to become a Certified Risk-Adjusted Coder (CRC) within one year and a Certified Clinical Documentation Specialist (CCDS) within 3 years is required. 

If you enjoy the challenges of helping to build a new program and are looking for a new career opportunity, we’d love to see your application.

  • Position Summary
    • Under the general direction of the Senior Director of Population Health, this position is responsible for facilitating complete, accurate and consistent documentation in the medical record supporting ICD-10 diagnosis code selection to the highest level of specificity to accurately represent each patient's current health status. This includes extensive prospective medical record review and interaction with providers, care team members, coders, and other staff members as appropriate. Active "at elbow" support and participation in team meetings and education of providers and staff is required.

      Support care teams, coordinate information flow, education and provider feedback.

      The position is responsible for performing quality reviews of ambulatory records to validate that documentation supports diagnosis code assignment to the highest level of specificity. This includes prospective, concurrent and retrospective reviews of ambulatory records to ensure accurate coding and to identify incomplete and/or inconsistent documentation of patient conditions that could impact the code selection and resulting risk adjustment assignment.

      The position is responsible to report results, findings and recommendations to the Senior Director of Population Health, in accordance with aCDI Program procedures and guidelines, and to assist in the development of process improvement activities to maintain data quality and integrity.

      This position may also act as a mentor, trainer and/or auditor for new and established Ambulatory CDI team members.

  • Required Minimum Knowledge, Skills, and Abilities (KSAs)
    • Education: BSN preferred.
    • License/Certifications: Current license as a registered nurse issued by the state of Maine. CRC in one year, CCDS in 3 years.
    • Experience: 5 years accrued nursing experience. Documentation auditing experience, 1 year COl CCDS preferred.
    • Strong ability to apply broad guidelines to specific documentation/coding situations, independently, utilizing discretion and a significant level of analytical ability.
    • Effective problem solving, analytical skills and communication skills.
    • Working knowledge Risk Adjustment methodology.
    • Working knowledge of Quality/HEDIS/gaps In care preferred
    • Working knowledge of Microsoft Office suite
    • Demonstrated ability to work independently and as part of a Care Team

We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow. Our package includes 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.

MaineHealth is a not-for-profit integrated health system consisting of eight local hospital systems, a comprehensive behavioral healthcare network, diagnostic services, home health agencies, and over 19,000 employees. It is the largest health system in northern New England and provides preventive care, diagnosis and treatment to 1.1 million residents in Maine and New Hampshire.

With a career at any of the MaineHealth locations, you’ll be working with healthcare 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 wellbeing of our communities and employees. We believe in fostering a work environment of strong commitment, compassionate caring and continuous improvement. Our care – and the science behind that care – is top rate. Join us and your abilities will be challenged and enhanced as you take your career to another level.


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