Clinical Documentation Improvement Nurse

Under limited supervision from the Director of Primary Care and Senior Director of Population Health, the Clinical Documentation Improvement (CDI) Nurse will assist GBMC Health Partners physicians and advanced practicing clinicians to accurately document patient clinical acuity and illness burden to improve risk management efforts. The CDI Nurse will review patient records, including ICD-10 diagnoses and Hierarchical Condition Categories (HCC) to identify and act on opportunities for improvement. This resource will also educate and work with providers, system leaders, and EPIC staff to maximize documentation accuracy and efficiency.EducationAssociate Degree in Nursing (ADN) with relevant experience required.Bachelor of Science (BSN) preferred.ExperienceMinimum of 5 years clinical nursing experience, preferably in outpatient or internal medicine settings.Experience in clinical documentation improvement (CDI), coding, or quality initiatives.Proven track record of collaborating effectively with physicians, coding teams, and interdisciplinary healthcare professionals.Demonstrated experience in providing provider education or training on clinical documentation or quality measures.Knowledge, Skills and AbilitiesStrong knowledge of clinical documentation best practices and standards for outpatient/internal medicineStrong knowledge of risk adjustment models, including HCC coding and value-based care reimbursementStrong knowledge of chronic disease processes such as CKD, CHF, COPD, diabetes with complicationsStrong knowledge of ICD-10-CM coding guidelines and query compliance standardsProficiency in conducting focused and efficient chart reviews to identify documentation gaps, clinical indicators, and opportunities for clarificationProficiency in interpreting clinical data (labs, imaging, history, physicals) to support accurate diagnosis captureProficiency in using EMRs and CDI/coding software tools for documentation review and query submissionCommunicate effectively and professionally with physicians, coders, and multidisciplinary teamsDeliver targeted education based on trends in documentation and provider performanceWork independently and prioritize high-impact cases using data-driven decision-makingAdapt to evolving outpatient documentation and compliance standardsLicensures, CertificationsCurrent Registered Nurse (RN) license in Maryland required.Certified Clinical Documentation Specialist (CCDS) certification is preferred.Principal Duties and ResponsibilitiesCollaborate with coding and clinical teams to enhance the accuracy and completeness of diagnosis coding across GBMC outpatient practices, supporting risk adjustment and reimbursement optimization efforts.Lead or support pre-visit documentation reviews to identify documentation gaps, coding opportunities, and clinical indicators requiring clarification prior to patient encounters.Contribute to both the strategic improvement and direct maintenance of patient problem lists in the electronic medical record (EMR), ensuring accuracy, relevance, and alignment with current clinical status, diagnoses, and coding standards.Physical RequirementsAbility to sit up to 90% of work timeAbility to concentrate and pay close attention to detail when typing and proofing for up to fifty (50%) percent of work timeAbility to travel to multiple locations and cover multiple practices, as neededWorking ConditionsPrimarily an ambulatory care setting, interviewing, assessing and educating patients and families, working with interdisciplinary staff up to 70% of time. Remainder of time in office environment.Conditions of EmploymentMaintain current and valid licensure and certifications.All roles must demonstrate GBMC ValuesGBMC ValuesValue DescriptionRespectI will treat everyone with courtesy. I will foster a healing environment.Treats others with fairness, kindness, and respect for personal dignity and privacyListens and responds appropriately to others' needs, feelings, and capabilitiesExcellenceI will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.Meets and/or exceeds customer expectationsActively pursues learning and self-developmentPays attention to detail; follows throughAccountabilityI will be professional in the way I act, look and speak. I will take ownership to solve problems.Sets a positive, professional example for othersTakes ownership of problems and does what is needed to solve themAppropriately plans and utilizes required resources for various job dutiesReports to work regularly and on timeTeamworkI will be engaged and collaborative. I will keep people informed.Works cooperatively and collaboratively with others for the success of the teamAddresses and resolves conflict in a positive waySeeks out the ideas of others to reach the best solutionsAcknowledges and celebrates the contribution of othersEthical BehaviorI will always act with honesty and integrity. I will protect the patient.Demonstrates honesty, integrity and good judgmentRespects the cultural, psychosocial, and spiritual needs of patients/families/coworkersResultsI will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.Embraces change and improvement in the work environmentContinuously seeks to improve the quality of products/servicesDisplays flexibility in dealing with new situations or obstaclesAchieves results on time by focusing on priorities and manages time efficientlyPay Range $73,465.95 - $126,056.34 Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.Equal Employment OpportunityGBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.