Maine's Capital Area

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MaineGeneral Health is offering an exciting opportunity for an individual to join our team as a Clinical Documentation Specialist. This position collaborates with medical staff to ensure the accuracy & integrity of medical documentation.


· Conducts concurrent and retrospective medical record reviews to ensure accurate and specific documentation of diagnoses and procedures.

· Identifies error 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.

The ideal candidate will have:

· Maine state licensure as a Registered Nurse (RN) preferred.

· Certified Clinical Documentation Specialist (CCDS) through Association for Clinical Document Improvement Specialists (ACDIS) or Certified Coding Specialist (CCS) through 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 preferred

· Ability to work collaboratively with Providers

Position Highlights:

· Competitive Benefit package including Health, Dental, and Disability options

· Generous earned time program

· Retirement plans with employer match

For more information or questions about staff positions, please contact our Recruitment Team by emailing or calling (207) 861-3440.