Clinical Documentation Specialist- 32hr/week

Make a system-wide impact beyond the bedside. At MaineGeneral Health, were more than a healthcare systemwere a community of professionals dedicated to innovation, compassion, and clinical excellence. As a Clinical Documentation Specialist, youll play a critical role in strengthening care quality, compliance, and financial sustainability through accurate and complete medical documentation.

What Youll Do:

• Conduct detailed, real-time and retrospective chart reviews to ensure accurate and completecomplete documentation of patient diagnoses and care.
• Work collaboratively with providers to ensure full capture of Hierarchical Condition Categories (HCCs), supporting accurate risk adjustment and reimbursement.
• Identify and address documentation or coding gaps that affect compliance, revenue, and patient care data.
• Bridge communication between clinical and coding teams to ensure clarity, accuracy, and audit-readiness.
• Educate providers and clinical teams on best practices for documentation that supports optimal care and compliance.
• Analyze and interpret the medical record documentation and provide appropriate physician queries to clarify documentation when needed for accuracy in patient care quality, compliance, and financial sustainability.

What Were Looking For:

• Maine RN license preferred.
• Preferred certifications:
  • CCDS (Certified Clinical Documentation Specialist) ACDIS
  • CCS (Certified Coding Specialist) AHIMA
• Strong understanding of medical terminology; experience in billing/coding is highly beneficial.
• Exceptional interpersonal skills with a focus on education and collaboration.
• Tech-savvy and comfortable using Microsoft Office and EHR systems.

Why Join MaineGeneral?

At MaineGeneral, youll find a supportive, mission-driven workplace where your voice is valued, and your growth is encouraged. We offer:

• A collaborative CDI team with deep experience and mentorship.
• Opportunities to influence quality improvement and regulatory readiness across the system.
• Competitive compensation and benefits, and a strong sense of community.

Supporting all aspects of our employees wellness physical, emotional and financial is a critical component of being a great place to work. With the wide range of benefits and programs available, employees have the resources they need to be well at every stage of life and plan for the future.

• We offer quality health, dental, and vision benefits and wellness programs and resources to provide employees access to resources for a healthy lifestyle and help manage health care costs.
• Employees have access to industry-leading leave for new parents.
• A generous earned time plan is offered to all employees - We believe employees need and deserve time away from work to observe holidays, be with family, go on vacation, or simply take care of themselves.

When life gets challenging, employees have access to our Employee Assistance Program for employees and anyone in their household.

• An employee discount program is available to all employees for services provided by MaineGeneral Medical Center.
• Loan Reimbursement is available for this position dependent upon current degree level. Please discuss benefit with the recruiter.
• Tuition Reimbursement is available to all employees to further develop skills and career.
• We offer eligible employees up to 2% of eligible pay in 403(b) company-matching contributions plus another 2% in the 401(a) retirement income plan.
• Three insurance plans are available to protect your family from the sudden loss of income in the event of your death, terminal illness or serious injury from accident.
• We offer both short-term and long-term disability insurance to replace a portion of your income if you become disabled and cannot work for a period of time.

Career Mobility:
Helping our employees develop their skills and grow their careers is critical to how we retain our talent and sustain our business. We do this by offering our teammates a variety of leadership-supported programs and learning and development resources for every stage of their professional development. We know that our employees are our most valuable resource they are how we grow our business and care for our community.

Equal Opportunity Employer M/F/Vet/Disability Assistive technologies are available. Application assistance for those requesting reasonable accommodation to the career site is available by contacting HR at ... .