Clinical Documentation Specialist

MaineHealth | Portland, ME

Posted Date 11/08/2019
Description 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.
Job Type
Geographic Region
Greater Portland/Casco Bay

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