Clinical Documentation Improvement Coder

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Position Summary
 

Job Profile Summary
The Clinical Documentation Improvement (CDI) Coder supports accurate clinical documentation and coding practices to ensure complete and compliant capture of diagnoses and services. This role reviews medical records, applies coding guidelines, and collaborates with clinical teams to ensure documentation supports accurate coding, risk adjustment, and quality reporting. The CDI Coder contributes to improved documentation integrity, regulatory compliance, and organizational performance.

Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

• Reviews medical records to ensure diagnoses and procedures are documented accurately and coded in accordance with established coding guidelines.

• Applies ICD-10-CM, CPT, and HCC coding principles to ensure accurate and compliant documentation and coding practices.

• Identifies documentation gaps that may affect coding accuracy, risk adjustment, and quality reporting.

• Collaborates with providers and clinical staff to clarify documentation through established query processes.

• Supports accurate risk adjustment coding through review and validation of chronic conditions and appropriate documentation.

• Ensures coding activities comply with regulatory standards, organizational policies, and coding best practices.

• Maintains accurate documentation of coding reviews, queries, and outcomes within applicable systems.

• Participates in quality improvement initiatives aimed at improving documentation integrity and coding accuracy.

• Assists in educating providers and staff regarding coding and documentation best practices.

• Collaborates with CDI, quality, and clinical teams to promote accurate clinical documentation.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

POSITION QUALIFICATIONS

Education:

• High School Diploma or equivalent required.

• Associate or Bachelor’s degree in Health Information Management or related field preferred.

Licensure/certification:

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required.

Experience:

• 2+ years of medical coding experience required.

• Experience with risk adjustment coding and HCC documentation preferred.

• Experience in ambulatory or primary care coding preferred.

Knowledge:

• Knowledge of ICD-10-CM and CPT coding guidelines

• Knowledge of risk adjustment models and HCC coding

• Knowledge of medical terminology and healthcare documentation standards

Skills:

• Strong attention to detail and analytical skills

• Strong written and verbal communication skills

• Organizational and time management skills

• Proficiency with electronic health records and coding systems

Abilities:

• Ability to review clinical documentation for accuracy and completeness

• Ability to manage multiple coding reviews efficiently

• Ability to collaborate effectively with clinical and administrative teams

Pay Range: $75,584.55 - $93,369.15 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan. In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [email protected]

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]