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.

• Associate Degree in Nursing (ADN) with relevant experience required.
• Bachelor of Science (BSN) preferred.

• Minimum 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.

• Strong knowledge of clinical documentation best practices and standards for outpatient/internal medicine
• Strong knowledge of risk adjustment models, including HCC coding and value-based care reimbursement
• Strong knowledge of chronic disease processes such as CKD, CHF, COPD, diabetes with complications
• Strong knowledge of ICD-10-CM coding guidelines and query compliance standards
• Proficiency in conducting focused and efficient chart reviews to identify documentation gaps, clinical indicators, and opportunities for clarification
• Proficiency in interpreting clinical data (labs, imaging, history, physicals) to support accurate diagnosis capture
• Proficiency in using EMRs and CDI/coding software tools for documentation review and query submission
• Communicate effectively and professionally with physicians, coders, and multidisciplinary teams
• Deliver targeted education based on trends in documentation and provider performance
• Work independently and prioritize high-impact cases using data-driven decision-making
• Adapt to evolving outpatient documentation and compliance standards

• Current Registered Nurse (RN) license in Maryland required.
• Certified Clinical Documentation Specialist (CCDS) certification is preferred.

• Collaborate 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.

• Ability to sit up to 90% of work time
• Ability to concentrate and pay close attention to detail when typing and proofing for up to fifty (50%) percent of work time
• Ability to travel to multiple locations and cover multiple practices, as needed

• Primarily 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.

• Maintain current and valid licensure and certifications.

I will treat everyone with courtesy. I will foster a healing environment.

• Treats others with fairness, kindness, and respect for personal dignity and privacy
• Listens and responds appropriately to others' needs, feelings, and capabilities

I 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 expectations
• Actively pursues learning and self-development
• Pays attention to detail; follows through

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

• Sets a positive, professional example for others
• Takes ownership of problems and does what is needed to solve them Appropriately plans and utilizes required resources for various job duties
• Reports to work regularly and on time

I will be engaged and collaborative. I will keep people informed.

• Works cooperatively and collaboratively with others for the success of the team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges and celebrates the contribution of others

I will always act with honesty and integrity. I will protect the patient.

• Demonstrates honesty, integrity and…