Clinical Documentation Improvement Nurse Coder (Certified)

PRIMARY DUTIES AND RESPONSIBILITIES

• Reviews patient medical records to ensure clinical documentation accurately reflects the patient’s conditions, severity of illness, and services provided.
• Collaborates with providers and care teams to clarify documentation and ensure accurate capture of diagnoses and conditions in accordance with coding and regulatory guidelines.
• Applies clinical knowledge and coding expertise to support accurate risk adjustment documentation, including identification and validation of HCC conditions.
• Performs concurrent and retrospective documentation reviews to identify opportunities for documentation improvement and coding accuracy.
• Safeguards documentation to align with regulatory and organizational compliance requirements.
• Communicates documentation clarification opportunities to providers through appropriate query processes that align with industry standards.
• Educates providers and clinical staff on documentation best practices, coding concepts, and the impact of documentation on quality reporting and risk adjustment.
• Supports clinical quality initiatives by identifying documentation gaps that impact quality measures and patient outcomes.
• Maintains accurate records of reviews, queries, and outcomes within designated tracking systems.
• Collaborates with coding, quality, and clinical leadership to improve documentation workflows and reporting accuracy.

POSITION QUALIFICATIONS

• Associate’s degree in nursing required.
• Bachelor’s degree in nursing preferred.
• Licensure/certification: Current, unrestricted Registered Nurse license required. Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) preferred.
• Experience: 3+ years of clinical nursing experience required. Experience in clinical documentation improvement, risk adjustment, or coding preferred. Experience in primary care, ambulatory care, or population health preferred.

KNOWLEDGE

• Knowledge of medical terminology, disease processes, and clinical documentation standards.
• Knowledge of ICD-10, CPT, and HCC coding methodologies.
• Knowledge of risk adjustment principles and quality reporting requirements.

SKILLS

• Strong analytical and critical thinking skills.
• Excellent written and verbal communication skills.
• Strong organizational and attention-to-detail skills.
• Proficiency with electronic medical records and clinical documentation systems.

ABILITIES

• Ability to collaborate effectively with providers and interdisciplinary teams.
• Ability to maintain confidentiality and comply with regulatory requirements.
• Ability to manage multiple priorities and meet deadlines.
• Ability to interpret and apply coding and documentation guidelines.